Journal of Marketing Management

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How does value co-creation transform quality of

life at the bottom of the pyramid?

Shahriar Akter, Mujahid Mohiuddin Babu, Md Afnan Hossain & Umme Hani

To cite this article: Shahriar Akter, Mujahid Mohiuddin Babu, Md Afnan Hossain & Umme Hani
(2021) How does value co-creation transform quality of life at the bottom of the pyramid?, Journal of
Marketing Management, 37:9-10, 962-992, DOI: 10.1080/0267257X.2021.1919745

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Published online: 11 May 2021.

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JOURNAL OF MARKETING MANAGEMENT
2021, VOL. 37, NOS. 9–10, 962–992
https://doi.org/10.1080/0267257X.2021.1919745

How does value co-creation transform quality of life at the

bottom of the pyramid?
Shahriar Akter a, Mujahid Mohiuddin Babu b
, Md Afnan Hossain a,c

and Umme Hani a

a
School of Business, University of Wollongong, Wollongong, Australia; bSchool of Marketing and
Management, Coventry Business School, Coventry University, Coventry, UK; cSchool of Business &
Economics, North South University, Dhaka, Bangladesh

ABSTRACT ARTICLE HISTORY

Value co-creation (VCC) has gained momentum in recent years due Received 31 March 2020
to the dramatic growth of digital technology. There is an ever- Accepted 7 December 2020
growing surge in academia and industry to understand the dimen­ KEYWORDS
sions and outcomes of VCC through various digital platforms. Value co-creation; customer
However, there is sparse literature on VCC in the bottom of the empowerment; quality of
pyramid (BoP) context, especially for technology-driven healthcare. life; bottom of the pyramid;
Drawing on the service-dominant (S-D) logic and consumer culture mHealth
theory (CCT), this research develops and validates a VCC model in
the context of mobile healthcare for poor patients at the BoP. The
findings identify VCC as a hierarchical construct that has a direct
and indirect impact on continuance intentions and patient’s quality
of life (QOLI) in which empowerment plays a mediating role. The
authors discuss the implications for advancing VCC research and
recommend avenues for linking it with economic (continuance) and
social benefits (i.e. QOLI).

Introduction
Various forms of information and communication technology (e.g. smartphones) play an
important role in co-creating value and enhancing the lifestyle of people at the bottom of
the pyramid (BoP) (Dey et al., 2019, 2016). The use of smartphones has been an effective
process by which BoP people, with little exposure to modern technology, can create and
obtain value. From the point of view of the service delivery system, value co-creation is no
longer limited to the producers’ offerings but rather is extended as a function to the
service provider and to consumers (Kristensson et al., 2008; Möller, 2006). Multiple inter­
actions between different economic actors (e.g. organisations, customers, service delivery
system, employees and technology) result in co-creation of value (Grönroos & Voima,
2013; Lusch & Vargo, 2014). The exponential growth of digitally enabled technology has
facilitated the co-creation process, as it has enabled the economic actors to exchange
resources through virtual interfaces. This has replaced the conventional notion of ‘high
touch, low tech’ which implied that service interactions occur only at physical interfaces or
touch-points (Bitner, 1990; Breidbach & Maglio, 2016). Digitally enabled technologies

CONTACT Mujahid Mohiuddin Babu ac4691@coventry.ac.uk School of Marketing and Management, Coventry
Business School, Coventry University, Coventry, UK
© 2021 Westburn Publishers Ltd.
 JOURNAL OF MARKETING MANAGEMENT 963

have expanded the boundaries of customer–firm interaction through real-time consump­

tion and has resulted in new opportunities and challenges for value co-creation
(Edvardsson et al., 2010).
With the rapid advancement of telecommunication technology, several digitally
enabled technologies, such as the mobile phone and the Internet, have become an
integral part of people’s lives. The adoption of mobile phone technology and the
Internet is no longer limited to the upper echelon of the socio-economic pyramid.
Instead, it has trickled down to the customers who remain at the BoP and survive with
a limited income. Therefore, given the increasingly important role of technology, as
suggested by several researchers, it is of immense significance that we investigate the
role of such technology for co-creation of value (Balaji & Roy, 2017; Breidbach & Maglio,
2016). Even in developing countries, the penetration of mobile usage is increasing
exponentially. In Bangladesh, the mobile phone’s coverage has reached 80% area of the
country, whereas the smartphone penetration is almost 40% (Islam, 2020). This has
enabled access to various services such as healthcare, social media, entertainment, mobile
financial services transfer, and ride-sharing (e.g. Uber, Pathao), which certainly has
enhanced the lives of people (Roy & Bell, 2019). Thus, the smartphone and Internet
have created and co-created value for all the relevant stakeholders and thus impacting
the users’ quality of life.
An organisation’s value co-creation process has a significant strategic impact on its
overall performance, as it generates value for customers as well as itself (Babu et al., 2020;
Dey et al., 2019; Ramaswamy & Ozcan, 2013; Taghizadeh et al., 2016). Extant literature
suggests that interactions between different stakeholders of the firm result in value co-
creation. By deploying and integrating resources, firms can facilitate interactions amongst
customers, which would co-create value (Vargo & Lusch, 2016). Value co-creation (VCC)
and service-dominant logic (S-D logic) (Vargo & Lusch, 2008) are quite integrated.
S-D logic suggests that value is co-created when there is an interaction between custo­
mers and suppliers, and digital technology, which eventually determines how the custo­
mers experience the service. Therefore, value is perceived as value-in-use, which is
generated through the collaborative effort among multiple factors, including customers
and the firm, and is no longer determined by the firm alone (Balaji & Roy, 2017). With
regard to digitally enabled technologies, VCC occurs when customers interact with the
technology while receiving the service, which certainly can encourage customers’ adop­
tion and continuous use of technology (Breidbach & Maglio, 2016; Vargo & Lusch, 2016).
Goods-dominant logic suggests that value is perceived as the final outcome of the value
chain where goods are converted into money (value-in-exchange) (Ramaswamy, 2009);
however, S-D logic extends the value chain to include the product or service usage. In
extant literature, several studies have adopted S-D logic, and emphasised value co-
creation as the basis of all marketing activities (Edvardsson et al., 2011; Ranjan & Read,
2016; Tynan et al., 2014). The adoption of mobile telephony and the Internet have
facilitated higher interaction before and during the service delivery process, as suggested
in the extant literature; therefore, S-D logic is deemed to be more appropriate than
conventional perspectives in assessing the customer’s experience with the technology
and thus enhancing their lifestyle (Balaji & Roy, 2017).
The use of smartphones has been instrumental in facilitating VCC in the bottom of the
pyramid (BoP) market, which has multi-faceted implications for customers, organisations
964 S. AKTER ET AL.

and society at large (Babu et al., 2020; Lei et al., 2020; M. Rahman et al., 2019). The BoP
market refers to the people who make up more than half the population of the world who
earn less than 2.50 USD a day, and who therefore struggle to meet their basic needs due
to severe poverty (Malik, 2014; Prahalad, 2012). The characteristics of the BoP market
indicates that it is primarily prevalent in developing countries. However, BoP markets are
estimated to be worth US$5 trillion for its consumption pattern and purchasing power
parity (Financial-Times, 2017). The BoP market is a potent consumer of mobile phone-
related services and the Internet, particularly in developing countries. The size of the BoP
market is increasing exponentially due to the affordability and availability of the technol­
ogy and the enormous facility and opportunity offered by these digital technologies
(Akter, Ray et al., 2013; Stork et al., 2013). Similarly, the adoption of digitally enabled
technology and devices, such as smartphones, has contributed significantly to the quality
of lives of BoP customers, as explored in a few studies (Baishya & Samalia, 2020; Berger &
Nakata, 2013). However, for the successful adoption of technology by this low-income
group of customers, the concerned stakeholders must have to transcend the technology,
innovation perspective and value delivery (Prahalad, 2012). In a low-income country, like
Bangladesh, with a population of 170 million, in January 2020, there were over
99.24 million internet users, of which 93.45 million are using the Internet through
smartphones, despite the significant number of BoP customers (BTRC, 2020). The reasons
for such growth in the internet users are fuelled by innovative value-added services (VAS)
by mobile operators and a vision by the Bangladesh government to respond to sustain­
able development goals (SDG) at the BoP, such as healthcare (GSMA Report, 2020)
In the extant literature, several research studies have addressed the adoption of mobile
phones by the BoP customers of Bangladesh and the potential impact (Babu et al., 2020;
Dey et al., 2019, 2016; M. Rahman. et al., 2019). The studies have also explored the extent
of value co-creation, social innovation, formulation of strategic alliance, and the overall
socio-economic progression. However, despite extensive research in the BoP context,
there is very limited research that has explored the BoP market’s value co-creation (VCC)
dimensions, especially when digital service delivery platforms are used. There is also
a paucity of research about how the overall value co-creation dynamics influence service
outcomes in this context (Breidbach & Maglio, 2016). Moreover, we have very limited
research knowledge about BoP customers’ access to healthcare and VCC through the
adoption of mobile phones. For a developing country like Bangladesh, providing health­
care to every citizen through a regular medical channel is very difficult. Smartphone apps
could play a very important role in this regard through mHealth apps. For example,
Shastho Batayon, the healthcare call centre of the health directorate of the country is
gaining increasing popularity among people as it provides various services such as
information about government hospitals, doctors, health services, and complaint man­
agement (Al Amin, 2020). Furthermore, because of its higher penetration rate, it creates
ample opportunities to co-create value, by providing safe and efficient healthcare services
and thus enhancing quality of life. Compared to a developed country, certainly,
a developing country’s BoP customers have very limited access to healthcare services.
However, the BoP customers have a very high rate of smartphone usage, which could be
a significant determinant for the adoption of various apps which have implications for
a healthy lifestyle (Alam et al., 2020). Moreover, from the theoretical point of view, most
S-D Logic driven research has focused on value co-creation in developed economies with
 JOURNAL OF MARKETING MANAGEMENT 965

limited attention given to the dynamics of VCC in the BoP market, which certainly has
different characteristics (Nahi, 2016). Thus, this research will answer the following two
research questions:

RQ1: What are the dimensions of value co-creation of mobile healthcare at the BoP?

RQ2: Is there any impact of value co-creation on customer empowerment, continuance

intentions and quality of life in this context?

In order to answer these research questions, this study will examine how VCC is taking
place in the BoP context and its impact on the customer’s empowerment, continuance
intentions and quality of life. This study explores technology-enabled VCC processes from
a socio-technical standpoint and provides more in-depth insights compared to studies
focusing on information technology (IT) alone. We have adopted the socio-technical
standpoint since this study encompasses several subsystems of socio-technical perspec­
tive such as technology, the BoP market, and societal impact. If any technological
innovation such as the smartphone is evaluated only by assessing its technical aspects,
systems and applications, it would be very short-sighted and would overlook the broader
impact that it may have on society as a whole. Furthermore, the contribution of techno­
logical innovations should be viewed through the socio-technical aspect as they are
greatly influenced by technical, political, social, and economic factors which need to
emphasise the interaction of consumers, industries, and the government in relation to
the technology (Lin et al., 2016). Therefore, the adoption of the socio-technical standpoint
will also shed light on both technical and interpersonal exchange patterns of various
stakeholders, such as the service provider and BoP customer, to provide a novel and
interesting perspective on the mobile platform-based healthcare. For this purpose, we
adopt the conceptual lens of S-D logic and service science to explore the roles of actors,
resources, and practices underlying technology-enabled VCC processes in the context of
BoP. Furthermore, consumer culture theory (Arnould & Thompson, 2005; Cross et al., 2018;
Peñaloza & Mish, 2011) is also instrumental in comprehending the outcome of VCC in the
BoP context. The study findings contribute to the academic and practitioner literature
significantly as it would explain the complex interplay of actors, resources, and practices
underlying technology-enabled VCC in the BoP context. The rest of the paper is structured
as follows. First, we assess the current literature on VCC and digitally enabled technology
in the BoP context using S-D logic, which led to the formulation of the research model and
related hypotheses. This is followed by the methods, analysis and discussion. Finally, the
paper provides a discussion on several theoretical and managerial implications, along
with limitations and future research directions.

Literature review
The concept of VCC has gained momentum in the last couple of decades (Balaji & Roy, 2017;
Dey et al., 2019; Grönroos, 2011; Ranjan & Read, 2016; Roy, Balaji et al., 2019; Vargo et al., 2008).
Researchers have considered the concept as an essential strategy for the BoP market. For
example, London et al. (2010) have established VCC as a crucial strategy in advancing poor
people’s quality of life. In a similar vein, several scholars have acknowledged the innovation
966 S. AKTER ET AL.

and appropriateness of technology as a necessary antecedent to improve the condition of the

BoP market (Prahalad, 2012; Slater et al., 2013). Likewise, Rashid and Rahman (2009) also stated
the importance of digital telecommunication to co-create value in the BoP market. The study
of VCC in the BoP segment sheds light on United Nations (UN) Sustainable Development Goals
(SDG), specifically good health, well-being, and economic growth (United-Nations, 2016).
Therefore, a company can improve the social and economic condition of communities by
practising shared value creation policies (Ma et al., 2019; Porter & Kramer, 2011). The following
section discusses the research paradigm of VCC at BoP, information communication technol­
ogy (ICT)-driven value co-creation in the BoP segment, theoretical underpinning, and the
development of hypotheses.

Value co-creation in the BoP market

Co-creation refers to ‘the joint, collaborative, concurrent, peer-like process of producing
new value, both materially and symbolically’ (Galvagno & Dalli, 2014, p. 644). In early 2000,
scholars acknowledged consumer-business co-creation as the mediator of supply and
demand relationships that interact and collaborate beyond the existing value chain
model (Prahalad & Ramaswamy, 2000). Subsequently, Prahalad and Ramaswamy (2004)
critique Porter’s (1985) value chain notion, as the concept overlooked the position of the
customer in the value creation method. The basis of the argument was that the producer
alone could not create value as they need the interaction with customers to generate
ideas for developing value. Many scholars have been emphasising VCC in the BoP
segment since early 2000 (Landrum, 2007; Prahalad & Hart, 2002; Simanis et al., 2008).
The process of VCC generates huge socio-economic benefit not only for BoP customers
but also for service providers (Hart & Milstein, 2003; London, 2008). Co-creating value
holds the potential to change the lives of poor people who are in the bottom of the
pyramid segment (Prahalad, 2004). A viable business model of joint value creation should
be developed for a long-lasting sustained economy (London et al., 2010). Besides, a few
studies have acknowledged the importance of understanding poor people’s thoughts to
introduce accurate offerings and enhance firm performance (Simanis et al., 2008). Despite
the common implication of VCC for poverty alleviation, business strategy and profit,
a more in-depth sector-wise exploration and careful monitoring is required of the BoP
segment (London, 2009; Walsh et al., 2005).

ICT-driven value co-creation at the BoP segment

Academic scholars acknowledged the importance of ICT in numerous literature (Dey et al.,
2016; Kapoor et al., 2015). ICT creates not only economic benefit but also builds a robust
social network (Alalwan et al., 2015). In a similar vein, technology empowers people to
accelerate the economy by improving the process capability and extending the social
networks (Dwivedi, 2007). The appropriation and use of the Internet and mobile phones in
the spectrum of ICT contributes greatly to boosting market efficiency and human devel­
opment (Rashid & Elder, 2009; Thapa & Sæbø, 2014). The people living at the BoP can also
change their fortunes by using their mobile phones (Dey et al., 2016). The authors
searched for ‘value co-creation’ and ‘Co-creation of Value’ in the title, abstract, and
 JOURNAL OF MARKETING MANAGEMENT 967

keywords of articles in the Scopus database. The result yielded 142 articles, and out of
these, only 10 papers (see Table 1) discussed VCC in the technology spectrum.
The literature review on VCC reveals that some of the research considered the sig­
nificance of ICT in VCC; and, none of the investigations focused on mobile platform-driven
VCC, specifically from BoP healthcare patients’ perspective. Dey et al. (2016) indicated that
poor inhabitants who have limited access to services to help improve their lives could
capture value via the use of the mobile telephone platform; however, more considerable
research attention in this area is required. Hence, this study considers mobile telephone
platforms’ significance to propose a VCC structure and observe its consequences on BoP
patients.

Theoretical underpinning and hypothesis development

Since 2004, the majority of the literature studies have addressed the idea of S-D logic as
the critical foundation of VCC. According to S-D logic, services should be delivered to the
customer using all sorts of tangible and intangible offerings, which is the primary base of
exchange where value is co-created with consumers (Vargo & Lusch, 2004). Vargo and
Lusch (2008) synthesised that providers and customer interaction co-create value gener­
ated through the set of specific resources. Resources can be formed in two categories: (1)
operand (e.g. physical products) and (2) operant (e.g. informative knowledge of custo­
mers and employees, culture, technology) (Hunt & Derozier, 2004).
Extent literature suggest that resources used in the service exchange incorporate the
social system and structure (Edvardsson et al., 2011). Thus, the current study argues that
S-D logic is appropriate in social construction theories where exchanging value is con­
sidered as a value transaction in a social context. Similarly, Pels et al. (2009, p. 328) also
considered S-D logic as a ‘social and economic process, and resources as becoming, not
being’. Social construction theories refer to humans learning, adjusting, and composing
their own choice within the social structures and systems (Edvardsson et al., 2011).
It has been witnessed that S-D logic has appeared as a fundamental structure for
research on VCC. Thus, the present study mainly investigated the theoretical underpin­
ning of S-D logic that complement social constructions. In the review process, it has been
observed that the concept of co-production and value-in-use appeared simultaneously as
the dimensions of VCC under the theoretical paradigm. The current study also considered
consumer culture theory (Arnould & Thompson, 2005; Cross et al., 2018; Peñaloza & Mish,
2011) to understand the outcome of VCC.
Consumer culture theory (CCT) presents vibrant associations amongst consumer activities,
the marketplace, and social purposes (Arnould & Thompson, 2005). The consumer culture
theme deals with consumers’ degree of credible actions include sensing, believing, and
executing specific response patterns (Askegaard & Kjeldgaard, 2002; Kozinets, 2002).
Numerous investigations have scrutinised the dynamic roles of consumers within the notion
of consumer empowerment (Denegri-Knott et al., 2006; Pongsakornrungsilp, 2010). In the
technology spectrum, empowerment refers to people’s ability to interact productively and
perform the task more efficiently than before (Amichai-Hamburger, 2008). By drawing on CCT,
Arnould and Thompson (2005) and Pongsakornrungsilp (2010) stated that consumers perform
a prominent role in the creation of their domain of consumption. CCT also addresses ‘the
dynamic relationships between consumer actions, the marketplace, and cultural meaning’

Table 1. Technology-enabled value co-creation (VCC) studies.
Source Aim
Breidbach et al. The aim of the study is to find out the impact of
(2013) technology-enablement for enhancing the service
system to co-create value.
Schmidt-Rauch and The study is driven by the concept of value co-
Schwabe (2014) creation which focuses on mobile telephone
services in the context of travel agencies’ sales
channels.
Dey et al. (2016) The study shows how BoP customers, more
specifically Bangladeshi farmers, can co-create
value using a mobile telephone, and the study also
offers a theoretical framework of value co-creation.
Balaji and Roy (2017) Internet of things (IoT) technology is considered as
a unique paradigm in this study. Drawing on
S-D logic, the study in retail settings suggests that
customer communication with technology such as
IoT generates value co-creation.
Zhang et al. (2017) This study acknowledges the diffusion of innovation Managers should emphasise informal
theory to propose the factors through which
generation Y engages while using mobile
telephone technology, and that this leads to the
co-creation of value.
Chuang (2018) The study investigates market orientation (MO) and It is critical to deploy integrated market orientation There is scope for identifying other moderators and/
value co-creation (VCC) and further examines how
to utilise an e-marketing system to expedite the
connection.
Akman et al. (2018) The study considers the social and individual factors Managers should focus on collaborative product
in the context of online cooperation- based
innovation in value co-creation.
Implications
Practitioners should consider social connectivity as While this study addressed connectivity as a unique
a prerequisite to co-create value successfully in
technology-oriented circumstances. The study also
provides guidelines to the practitioners for
managing social connectivity.
The travel agent can use the newly designed system Mechanisms of trust and other user-level goals, such
for customers to generate continuous support
through interaction that likely enhances customer
retention and loyalty.
Providers can design a strong distribution network so There is scope to study BoP markets in other socio-
that farmers can top up their mobile telephone;
providers can also demonstrate how to use mobile
telephones for creating value and can create
community engagement for the BoP segment.
Retail outlets should consider adopting IoT
technologies that have superior functionality to
ensure user-friendliness. They should also consider
the aesthetic appeal and presence of the IoT to co-
create value.
communications when engaging generation Y, and
also ensure ease of use of technology, to
encourage consumer innovativeness to co-create
value through the mobile telephone platform.
from sellers’ perspective while adopting an
e-marketing system that consequently facilitates
value co-creation and generates trust among
consumers.
development through managing collaborative
innovation in the online community that co-creates
value.
968
Scope for further research
rational theme that can be considered in the future
to investigate the further role of technology in
service systems within the VCC spectrum,
numerous perspectives of connectivity are not fully
S. AKTER ET AL.
explained.
as sensory needs and performance, can be
investigated further in the aspect of tourism and
mobile telephone services.
cultural contexts and also in various sectors such as
healthcare by considering mobile telephone
platforms and VCC.
Future investigations could expand the research
theme by examining the role of technology in
value co-creation and the outcome, such as
continuance intention, and quality of life not only
in retail but also in other sectors.
There is scope to extend the findings of this study and
investigate other relevant variables in different
segments such as the BoP segment rather than
considering only the generation Y.
or mediator variables that could create greater
value co-creation outcomes for customers.
Other activities could be examined further in future
research, such as information seeking in a set of
value co-creation activities within the context of
online cooperation-based innovation.
(Continued)
Table 1. (Continued).
Source Aim
Roy, Singh et al. This study conceptualises smart experience co-
(2019) creation (SEC) and the smart servicescape by
investigating smart consumers who voluntarily
engage in value creation activities.
Dey et al. (2019) The study investigates how ICT upgrading is attained Firms can apply the co-creation tool for upgrading
in the Bangladeshi mobile telephone context in the
VCC paradigm.
M. Rahman. et al. The study investigates numerous factors and their
(2019) interrelationships that guide the smartphone
industry’s technological innovation, particularly in
West Bengal, India and Bangladesh. The
investigation considers VCC and develops
a dialectical perspective.
Implications
Managers need to understand the SECs fundamental There is scope for creating and validating a new SEC
structure and the users’ focus on aesthetics,
personalisation, functionality, social presence and
interactivity.
technology and can use the proposed holistic
model, which illustrates the inter-relationship
between various stakeholders.
Managers of the smartphone industry should take
appropriate marketing initiatives,which include
product design, to minimise the effect of co-
destruction. A firm can generate co-production
through engagement among stakeholders.
Scope for further research
scale, principally for smart retailing.
There is scope for further investigation to fully explain
the speed and efficiency of the processes and
relationships in this aspect.
There is scope for empirical investigations to validate
the research framework introduced in this
particular study.
JOURNAL OF MARKETING MANAGEMENT
969
970 S. AKTER ET AL.

(Arnould & Thompson, 2005, p. 868). Thus, technology-enabled VCC might create relative
benefits for customers and could generate customer trust and loyalty, using continuity as part
of customer behavioural intention. Previously, researches showed that comparative advantage
significantly influences customers’ technology adoption intention (So & Sun, 2010; Tsai et al.,
2010). In a similar vein, a study by Lu et al. (2015) suggests that relative advantage ascertains
the behavioural intentions, which means a continuance intention of a particular service. The
study also assumes that the technology-driven VCC and attainment of the service is cost-
effective from a BoP customer perspective, and might generate satisfaction and enhance their
quality of life. Service providers should interact and engage with the customers memorably in
a unique form to intensify the experience (M. S. Rahman et al., 2018; Trudeau & Shobeiri, 2016),
which will likely improve quality of life in the BoP segment. The current research looks into the
concept of mobile platform-driven VCC and develops the hypotheses to investigate empiri­
cally healthcare patients who are at the BoP.

Proposed conceptual model of value co-creation for BoP patients

Technological advancements such as mHealth significantly contribute to enhancing market
efficiency and human development (Donner & Escobari, 2010; Thapa & Sæbø, 2014). mHealth
services have gained momentum in the developing world (Akter et al., 2019; Dey et al., 2019).
Using mHealth, a patient (e.g. BoP patients) can receive consistent health services (e.g. medical
consultation, information on diseases, e.g. COVID-19, ambulance services, etc.) via the mobile
platform, where consumers play an active role and create value together with the healthcare
provider (Kohler et al., 2011). Drawing on the extant theories of VCC as discussed in the
previous section (Ranjan & Read, 2016; Sheth, 2019), the study puts forward the VCC model for
mobile healthcare patients at the BoP (see Figure 1). Theoretically, using the guidelines of
Ranjan and Read (2016), we conceptualise the VCC model for healthcare as the third-order
model in which the second-order dimensions (i.e. co-production and value in-use) are reflected

Figure1. Research model.

 JOURNAL OF MARKETING MANAGEMENT 971

by its respective first-order dimensions (i.e. information, access, interaction, experience, perso­
nalisation and privacy). Methodologically, the formulation and measurement of a reflective-
formative VCC model is based on the guidelines of Becker et al. (2012), which is further
discussed under Findings (Data analysis). The following section discusses the construction of
the conceptual model and relevant hypotheses.

Co-production
Co-production is the integration of mutual resources (Ballantyne & Varey, 2008) through
dialogue (Grönroos, 2012) and collaboration (Lusch et al., 2007) in value composition. Hu
and McLoughlin (2012) defined co-production as to co-working with customers. Similarly,
Fang et al. (2008) and Lemke et al. (2011) mentioned co-production as the participation of both
service providers and recipients during the service design process. Besides, social and eco­
nomic actors carried out a set of procedures of co-production (Achrol & Kotler, 2012; Vargo &
Lusch, 2008). The review of the literature synthesises three underlying components of co-
production that can be designed: information, access, and interaction. Information sharing in
any participation generates a better outcome, such as settlement, better diagnosis, and need
evaluation (Grover & Kohli, 2012; Powell & Swart, 2010). Accordingly, learning from such
participation generates a competent process in service design (Maglio & Spohrer, 2008).
Access to the customers’ preferences is key to success and through which both parties’ ideas
can produce a competent service (Budzik et al., 2001; Joshi & Sharma, 2004; Satyanarayanan,
1996), where the service provider considers the customer role to be as crucial as its own in the
process. On the other hand, Interaction refers to the participation of several individuals
(Grönroos & Ravald, 2011; Kohler et al., 2011). A firm can understand customer needs by
interacting with them (Merz et al., 2009). The process of interactive exchange generates
customer-centric solutions (Bagozzi et al., 2012). Overall, combining information, access and
interaction, we put forward the hypothesis that:

H1: Co-production of mHealth service positively influences value co-creation.

Value-in-use
Value-in-use goes beyond the concept of co-production, where a firm needs to know the
consumer’s feedback to understand service proposition, service maintenance, and customer
using patterns (Vargo & Lusch, 2004). Value can be generated through offerings and interac­
tion; however, it can also be enhanced through the consumption process (Moeller, 2008; Vargo
& Lusch, 2004). In a similar vein, Gummerus and Pihlström (2011) mentioned that value-in-use
is obtained from the user’s usage patterns. The review of the literature synthesises three
underlying components of value-in-use that can be designed: experience, personalisation, and
privacy. Experience refers to the feelings that are generated through the firm’s offering (Bolton,
2004). It creates intrinsic value through customers’ memorable interactions with the providers
(Ballantyne & Varey, 2008; Lusch & Vargo, 2006). The personalisation process helps to articulate
the benefit, value, or fun for the user (Karpen et al., 2012; Lemke et al., 2011). Culture and
behavioural changes reinforce the process of making a personalised offering (DeBerry-Spence,
2008) that creates a supportive atmosphere for customers (Macdonald et al., 2011). As in co-
production, both parties interact; thus, privacy is a concern. Information minimisation requires
972 S. AKTER ET AL.

firms to restrict the variety of data they assemble and to preserve and replace the data they no
longer need (Wedel & Kannan, 2016). Further, personally identifiable information can be
removed (data anonymisation) through the procedure called K-anonymisation, where each
record is indistinguishable (Miller & Tucker, 2011). Therefore, based on the previous discussion,
we have formed value-in-use by combining experience, personalisation and privacy and have
put forward the following hypothesis.

H2: Value-in-use positively influences value co-creation.

Value co-creation, continuance intention and patients empowerment

Mobile platform-driven value co-creation among the providers and poor patients may
significantly enhance patients’ empowerment and continuance intention of using the
services. Empowerment as a concept has been addressed in many forms of studies such as
citizens’ participation and empowerment in political studies (Bucy & Gregson, 2001;
Sørensen, 1997); empowerment of employees acknowledged in management studies
(Rapp et al., 2006; Spreitzer, 1995); and users’ empowerment addressed in information
system studies (Füller et al., 2009; Grover & Kettinger, 1997). Management studies
describe empowerment as a perceived power or control of an individual over the system
(Bacharach & Lawler, 1980). According to Palumbo (2017), patient empowerment may
emerge as the outcome of VCC where patients will have the control over their health-
related condition and will be conscious of the available resources in the healthcare service
system. Thus, in this study, we also assume that the mobile platform-driven VCC empow­
ers the patients who are at the BoP. Similar to Auh et al. (2019) research, this study
considers empowerment further from two viewpoints: (1) perceived patients’ participa­
tion impact and (2) perceived patients’ participation worth (see Table 3). Further, patients’
satisfaction with health services is generally considered as the behavioural intention that
is reflected through loyalty, revisit intention, or word of mouth (M. S. Rahman et al., 2018).
However, one stream of research recommended that satisfaction influences continuance
intention (Akter, D’Ambra et al., 2013; Bhattacherjee, 2001a). Other streams of investiga­
tion observed satisfaction as a mediator between the quality of service and behavioural
intention (Brady & Robertson, 2001; Dabholkar et al., 2000). According to Bhattacherjee
(2001b), users’ continuous usage behaviour after accepting a service is reflected in the
term ‘continuance intention’. Continuance intention is a crucial determinant for the
execution of service arrangements (Limayem et al., 2007). Despite the benefit of the
themes of VCC, empowerment, and continuance intentions, none of the academic
researches considered the idea in one frame, particularly from BoP patients’ perspective.
Therefore, the current study proposes the following hypotheses for the empirical
investigation.

H3: Value co-creation positively influences patients’ service continuance intention.

H4: Value co-creation positively influences patients’ empowerment.

H5: Patients’ empowerment positively influences patients’ service continuance intention.

 JOURNAL OF MARKETING MANAGEMENT 973

Value co-creation, quality of life and patients’ empowerment

Mobile platform-driven value co-creation may significantly enhance the patient’s quality of life
along with empowerment. Value co-creation begins when both the providers and the
receivers participate and connect independently in a service setting (Sheth, 2019). The relation­
ship may unearth the issue of patients’ empowerment and quality of life. The term ‘quality of
life’ is generally considered as a sense of well-being (Sirgy et al., 2006; Yuan, 2001). Quality of life
is considered to be measured from various domains, such as healthcare, leisure time with
family, etc. (Lee et al., 2002; Sirgy & Cornwell, 2001). According to Pick et al. (2014), technolo­
gical advancement can bring quality of life, particularly in a developing country, by enhancing
the living standards of people.
The socio-economic progression of a developing country, such as people’s quality of
life, may improve due to the adoption of a digital platform (Kapoor et al., 2015; Walsham,
2010). In the healthcare literature, quality of life is viewed as an individual, subjective
construct which measures the overall well-being of a person (Dagger & Sweeney, 2006). In
spite of the importance of value co-creation, empowerment, continuance intentions, and
quality of life, there is a lack of research combining these concepts in one frame,
particularly from BoP patients’ perspective. Thus, the current study proposes the following
hypotheses for the empirical investigation.

H6: Value co-creation positively shapes patients’ quality of life.

H7: Patients’ empowerment positively influences patients’ quality of life.

H8: Patients’ service continuance intention positively shapes the patients’ quality of life.

Mediating effects of customer (or, patient) empowerment

A high level of customer empowerment is the key goal of a value co-creation platform because
empowerment influences continuance intentions and quality of life. We identify empower­
ment as a mediator because VCC in healthcare using a mobile platform influences patient
empowerment, which in turn affects patients’ continuance intentions and quality of life. Also,
we identify empowerment as a mediator because the VCC influences outcome constructs
without any direct involvement of a mediator (Baron & Kenny, 1986). Indeed, marketing and
psychology (Ajzen & Fishbein, 1980) research have largely identified a mediator as a cognitive
belief (i.e. empowerment) which links affective attitude (i.e. VCC) with conative outcomes
(continuance and quality of life). In our research context of mHealth at the BoP, patient
empowerment plays a critical role between VCC and continuance intentions and VCC and
quality of life for sustainable developments. Therefore, the study put forward the following
hypotheses for further empirical investigation.

H9: Customer empowerment mediates the influence of value co-creation on continuance

intentions.

H10: Customer empowerment mediates the influence of value co-creation on quality of

life.
974 S. AKTER ET AL.

Methodology
Instrument development
Scales were adapted from prior literature and contextualised for mHealth services at the
BoP. Table 3 shows the constructs and their items in details with sources. We used 7-point
Likert scale-based items. Due to the contextualisation of the research setting, first, we
translated the original English questionnaire into Bengali, and second, we retranslated the
Bengali version into English until a panel of experts, fluent both in English and Bangla,
confirmed that the two versions were reasonably comparable (Akter et al., 2019). The pre-
test of the instrument was conducted with 20 respondents to undertake some revisions
and confirm its wording, sequence and scales.

Sampling
We used a leading market research firm to identify patients (or, customers) who had had
experience with a popular mHealth service in Bangladesh in the past 3 months. The
platform is widely known as ‘Shastho Batayon’, which is a 24/7 service providing health-
related consultations and advice from registered physicians. People across the country
can access this service by dialling 16,263. This health platform received 1,066,168 medical
calls in 2018, 1,048,518 in 2017 and 1,226,469 in 2016 (http://dashboard.dghs.gov.bd) We
approached a panel of 425 respondents, and 230 (54%) completed the survey. Due to
missing values and inconsistent answers, we excluded 20 responses, and finally, 210
responses were analysed. The sample demography analysis presents a variety of respon­
dents across genders, age, income, location, and occupation. Table 2 shows poor patients
at the BoP, representing various income groups and professions, with 57% of them
earning less than 50 USD per month (see Table 2).

Findings
Data analysis
We identify VCC as a hierarchical construct with reflective-formative dimensions. We
propose the second-order co-production (COPR) and value-in-use (VAIU) as reflective
constructs, which ultimately form VCC. Following the guidelines of Becker et al. (2012),
we used a repeated indicator approach to estimate the second- and third-order con­
structs. As a result, the study created a hierarchical VCC, which represents all the items of

Table 2. Demographic profile of respondents.

Items Categories % Items Categories %
Gender Male 52 Age 18–25 21
Female 48 26-33 29
Location Urban 33 34–41 25
Rural 67 42-49 20
50+ 5
Income <50 USD 57 Occupation Working full time 27
51 USD- 100 USD 18 Working part-time 28
(per month in US $) 101 USD – 200 USD 15 Stay-at-home spouse 35
201 USD + 10 Others 10
Table 3. Assessment of first-order, reflective model.
Constructs Items Loadings CR AVE
Information (INFO) (Ranjan & Read, 2016) 1. The mHealth provider was open to my ideas and suggestions about its existing services or towards developing 0.926 0.927 0.762
a new service.
2. The mHealth provider provided sufficient illustrations and information to me. 0.895
3. I spent time and effort sharing my ideas and suggestions with the mHealth provider in order to help it improve its 0.941
services and processes further.
4. The mHealth provider provided a suitable environment and opportunity for me to offer suggestions and ideas. 0.709
Access (ACCS) (Ranjan & Read, 2016) 1. The mHealth provider had easy access to information about my preferences. 0.724 0.884 0.724
2. The processes of this mHealth provider are aligned with my requirements (i.e. the way I wish them to be). 0.763
3. The mHealth provider considered my role to be as important as its own in the process. 0.872
4. The mHealth provider considered my information in determining the final outcome. 0.875
Interaction (INTR) (Ranjan & Read, 2016) 1. During the process, I could conveniently express my specific requirements. 0.886 0.891 0.674
2. The mHealth provider conveyed to its consumers the relevant information related to the process. 0.885
3. The mHealth provider allowed sufficient consumer interaction in its service processes. 0.791
4. In order to get the maximum benefit from the mHealth service process, I had to play a proactive role during my 0.708
interaction.
Experience (EXPR) (Ranjan & Read, 2016) 1. It was a memorable experience for me (i.e. the memory of the process lasted for quite a while). 0.886 0.901 0.752
2. Depending upon the nature of my own participation, my experiences in the process might be different from other 0.860
consumers.
3. It was possible for a consumer to improve the health platform by experimenting and trying new things. 0.855
Personalisation (PERS) (Ranjan & Read, 2016) 1. The benefit, value, or fun gained from using the health platform (or, the product) depended on the user and the 0.887 0.942 0.843
usage condition.
2. The mHealth provider tried to serve the individual needs of each of its consumers. 0.959
3. Different consumers, depending on their needs, involve themselves differently in the health platform (or, with the 0.908
service).
Privacy (PRIV) (Akter et al., 2019) 1. mHealth platform protects my personal information. 0.883 0.931 0.818
2. mHealth platform does not share information with others. 0.959
3. mHealth platform offers me a meaningful guarantee. 0.911
Perceived customer participation impact 1. I am very well aware of the positive impact that my participation has on this health platform. 0.767 0.808 0.585
(PCPI) (Auh et al., 2019)
2. I am very well aware of the ways in which my participation is benefiting this health platform. 0.711
3. I have a positive impact on this health platform through my participation in the service process. 0.812
Perceived customer participation worth 1. This health platform cares about my participation in the service process. 0.936 0.958 0.883
(PCPW) (Auh et al., 2019)
2. This health platform appreciates my participation in the service process. 0.936
JOURNAL OF MARKETING MANAGEMENT

3. This health platform values my participation in the service process. 0.936

Continuance Intentions (CONT) 1. I intend to continue using mHealth platform to gain access to medical information services. 0.920 0.943 0.846
(Akter et al., 2019)
975

(Continued)
 976
S. AKTER ET AL.

Table 3. (Continued).
Constructs Items Loadings CR AVE
2. My intention is to continue using this service rather than use any alternative means (e.g. going to local clinics).3. I 0.894
will not discontinue my use of this health service.
3. I will not discontinue my use of this health service. 0.945
Quality of Life (QOLI) (Akter et al., 2019) 1. mHealth platform enabled me to improve my overall health. 0.865 0.944 0.807
2. In most ways, my life has come closer to my ideal since I started using this healthcare service. 0.908
3. I have been more satisfied with my health thanks to this service platform. 0.895
4. So far, this service has helped me to achieve the level of health I most want in life. 0.884
 JOURNAL OF MARKETING MANAGEMENT 977

the first-order constructs (i.e. information, access, interaction, experience, personalisation,

and privacy). The study applied Partial Least Squares (PLS)-Structural Equation Modelling
(SEM) because, first, it is suitable for complex, higher-order modelling, with more than 10
constructs (Akter et al., 2017), and second, issues regarding factor indeterminacy, factor
identification, distributional assumptions, and sample size can be appropriately handled
by PLS-SEM (Chin, 2010; Hair et al., 2019). Finally, we selected PLS-SEM to establish more
theoretical parsimony and model simplicity (Wetzels et al., 2009). As part of the SmartPLS
3.0 (Ringle et al., 2015) application, we used a nonparametric bootstrapping with a path
weighting scheme for the inside approximation with 5000 replications to obtain the
standard errors of the estimates (Chin, 1998; Efron & Tibshirani, 1994; Hair et al., 2017).

Measurement model
The study represents nine first-order constructs: information, access, interaction, experience,
personalisation, privacy, empowerment (perceived customer participation impact, perceived
customer participation worth), continuance intention, and quality of life (see Table 3). To
ensure convergent validity, the study estimated loadings (>0.70, p < 0.001), average variance
extracted (AVE) (>0.50) and composite reliability (>0.80), which all exceeded the cut-off values
(Hair et al., 2017; Henseler et al., 2016). For example, PCPI has the lowest CR (0.808) and AVE
(0.585), whereas CONT has the highest AVE (0.846) and QOLI has the highest CR (0.944). Thus,
the study confirmed adequate reliability and convergent validity of the measurement model
using loadings CR and AVE (Fornell & Larcker, 1981; Henseler et al., 2016).
In order to ensure discriminant validity, the study estimated the square root of the AVEs to
evaluate correlation coefficients following the guidelines of Fornell and Larcker (1981). Table 4
shows these values on the diagonal, which highlightpffiffiffiffiffiffiffiffithat the constructs do not contain similar
items and are distinct from each other because AVE > correlations. Also, the study estimated
cross-loadings to confirm that each item represents more of its own construct than other
constructs (Hair et al., 2017). After confirming the satisfactory performance of the first-order
model, the study progressed to evaluate the second-order model and the structural model in
the next sections. The study also examined the HTMT (heterotrait-monotrait) ratio to ensure
discriminant validity as all the constructs satisfied the cut-off ratio of 0.9 (Henseler et al., 2015).
Due to the hierarchical nature of the VCC model, the study estimated the second-order
COPR and VAIU constructs. The third-order VCC construct consists of 22 items, of which 12
items (4 + 4 + 4) represent COPR and 9 items (3 + 3 + 3) represent VAIU. We have proposed

Table 4. Descriptive statistics, correlations and AVEsa.

Construct Mean SD INFO ACCS INTR EXPR PERS PRIV PCPI PCPW CONT QOLI
INFO 5.713 1.124 0.873
ACCS 5.417 1.195 0.363 0.811
INTR 5.521 1.175 0.314 0.414 0.821
EXPR 5.265 1.238 0.249 0.363 0.326 0.867
PERS 5.923 1.129 0.439 0.225 0.408 0.292 0.918
PRIV 5.612 1.238 0.286 0.218 0.413 0.337 0.433 0.905
PCPI 5.756 1.163 0.379 0.342 0.426 0.219 0.303 0.281 0.765
PCPW 5.767 1.028 0.375 0.246 0.410 0.278 0.312 0.215 0.363 0.940
CONT 5.586 1.232 0.383 0.301 0.472 0.183 0.363 0.285 0.342 0.246 0.920
QOLI 5.576 1.114 0.304 0.386 0.466 0.256 0.303 0.271 0.425 0.406 0.368 0.898
a
Square root of the AVE on the diagonal.
978 S. AKTER ET AL.

a reflective-formative model in which second-order constructs (i.e. COPR & VAIU) are reflec­
tive, and the third-order VCC construct is formative. Thus, we confirmed that the loadings, CR
and AVE of the second-order constructs are significant (see Table 5). Also, we confirmed that
the weights of the third-order VCC construct is significant. In addition, the collinearity test met
the required threshold by showing lower collinearity (variance inflation factor or, VIF < 5).
As part of estimating the hierarchical-measurement model, we have calculated the
variance of the second-order constructs (i.e. COPR and VAIU), which explain 73% and 39%
of the variance, respectively (see Table 6). Similarly, COPR is reflected by information
(85%), access (68%) and interaction (86%), and VAIU is reflected by experience (66%),
personalisation (79%) and privacy (79%). The results show that all the path coefficients are
significant at p < 0.05. Due to the formative nature of the higher-order constructs, we
have estimated an R2 value of unity for VCC (Becker et al., 2012).

Structural model
To check the validity of the proposed hypothetical relationships, we have estimated the
properties of the structural model in terms of beta coefficients and t-statistics (see Figure 2).
First, COPR-VCC and VAIU-VCC relationships provide standardised beta coefficients of 0.730
and 0.392 respectively, which are significant at p < 0.05. Thus, H1 and H2 were accepted.
Similarly, the path coefficients of 0.314 (VCC-CONT), 0.627 (VCC-EMPR) and 0.424 (EMPR-CONT)
confirm that these links were significant at p < 0.05, and thus support hypotheses H3-H5. We
also assessed the path coefficients of the links between VCC-QOLI, EMPR-QOLI and CONT-
QOLI, which were significant at p < 0.05, supporting H6-H8. Overall, the findings of the study
show a significant positive impact of the higher-order VCC on EMPR, CONT and QOLI (see
Table 7).
In order to investigate the indirect effects of EMPR, the study estimates the VCC-EMPR-
CONT link and VCC-EMPR-QOLI link. Using the procedures of Preacher and Hayes (2008), the
study evaluates the mediating effect of EMPR applying bootstrapping on a 95% of confidence

Table 5. Measurement properties of the hierarchical VCC model.

Third-order formative construct Weights of items VIF p-value
Value co-creation (VCC) 0.105–0.288 1.33–1.76 P < 0.05
Second-order reflective constructs Loadings of items CR AVE
Co-production (COPR) 0.616–0.814 0.906 0.552
Value in use (VAIU) 0.645–0.800 0.882 0.559

Table 6. Measurement properties of the hierarchical VCC model.

Third-order construct Relationships with second-order formative dimensions β t-stat
Value Co-creation (VCC) Co-production 0.730 20.310
Value in use 0.392 3.409
Second-order constructs Relationships with first-order reflective dimensions β t-stat
Co-production (COPR) Information 0.859 43.175
Access 0.679 9.747
Interaction 0.857 33.599
Value in use (VAIU) Experience 0.664 13.430
Personalisation 0.795 21.996
Privacy 0.797 26.317
 JOURNAL OF MARKETING MANAGEMENT 979

Figure 2. Structural model.

Table 7. Results of the structural model.

Structural model Path coefficients Standard error t statistic
COPR →VCC 0.730 0.0360 20.310
VAIU →VCC 0.392 0.0360 10.967
VCC →CONT 0.314 0.0740 4.239
VCC →EMPR 0.627 0.0440 14.343
EMPR →CONT 0.424 0.0703 3.511
VCC →QOLI 0.264 0.0750 2.512
EMPR →QOLI 0.152 0.0780 1.947
CONT →QOLI 0.420 0.0630 6.625

interval. Using variance accounted for (VAF) criteria (Akter et al., 2011), the size of the
mediating effect of EMPR is calculated as 47% for the VCC-EMPR-CONT link and 28% for
the VCC-EMPR-QOLI link, which has been proven as a significant partial mediator (see Table 8).
The total variance explained by the research model as R2 for outcome constructs is
0.390 for EMPR, 0.441 for CONT and 0.521 for QOLI. These findings confirm the significant
impact of VCC on outcome constructs, which are significantly large, as suggested by
Cohen (1988) as a threshold for R2 effect sizes. As an additional analysis, the study
analysed common method variance (CMV) using the marker variable technique (Lindell
& Whitney, 2001). We used a weakly related variable in the nomological chain, and the
findings did not show any significant association between a marker variable and any
construct. As recommended by Shmueli et al. (2019), we assessed the predictive power of
a VCC in examining the model’s out-of-sample predictive ability. As such, we ran the
PLSpredict for a sub-division of the sample into 10 and 10 repetitions. All the indicators of

Table 8. Results of the mediation testing.

Significance Significance
Direct effect t-value (p < 0.05) Indirect effect t-value (p < 0.05)
VCC-CONT (H9) 0.314 3.259 0.000 0.266 5.283 0.000
VCC-QOLI (H10) 0.264 2.987 0.003 0.100 1.970 0.030
980 S. AKTER ET AL.

our outcome construct, QOLI, showed a lower root-mean-square error (RMSE) value in
PLS-SEM compared to RMSE values of the linear regression model (LM) benchmark. As
such, the findings provided support for the higher predictive power of the research model
(Shmueli et al., 2019).

Discussion and conclusion

In this study, we have developed and validated a conceptual model explaining the significance
of value co-creation for enhancing the customer empowerment and overall quality of life in
the context of mobile healthcare at the BoP. Drawing on the S-D logic, this study empirically
tests the research model that identifies COPR and VAIU as the components of VCC.
Furthermore, the influence of VCC is also examined over the BoP patients’ continuance of
healthcare, empowerment, and how it improves the overall quality of life in the context of
a developing country. The outcomes of this study advance the implication in the achievement
of a developing country’s health goals as delineated in the SDG.
The results demonstrate a significant explanatory power of VCC on CONT, EMPR and QOLI
as all the hypotheses are being supported at p < 0.05, except for H7, which is accepted p < 0.10.
COPR and VAIU are the two components that constitute the VCC construct. This finding
reinforces the earlier outcomes, which suggests that co-production and customer participation
and value-in-use enhance the development of VCC. In order to establish VCC, it is important to
ensure that customers are also ‘co-working with the firms’, ‘interacting through mutual
exchange’ and facilitating knowledge sharing. On the other hand, VAIU complements the
COPR and emphasises the customers’ knowledge about the usage and benefit of the value
proposition, which are instrumental in explaining the VCC (Ranjan & Read, 2016). Of these two,
COPR (73%) explains more VCC than VAIU (39%). One explanation for this could be attributed
to the fact that in a service setting, customers are always co-producers of services and co-create
value since they mobilise knowledge and other resources which influence the success of
a value proposition (Ordanini & Pasini, 2008). From a technology perspective, co-production,
coupled with resource integration plays a more critical role in analysing the customers’
perception of value-in-use, and eventually VCC (Hilton & Hughes, 2013).
Moreover, VCC emerged as a strong predictor for CONT (0.44), EMPR (0.39) and QOLI
(0.52) for the healthcare patients at the BoP. A primary explanation could be that mobile
healthcare has become an affordable technological device which has enabled those at the
BoP to explore the various important needs in their lives, such as health and well-being.
Their spontaneous interaction with this digital system and working together with the
health professionals has not only empowered them to improve their standard of living
but has also facilitated the continuation of this service platform. Furthermore, the study
findings signified the mediating role of empowerment in the relationship between VCC
and QOLI and between VCC and CONT though it emerged out to exert partial mediation
in the earlier relationship.

Theoretical contributions
Our study findings will reinforce the idea that COPR is an integral part of the VCC and deviates
from the school of thought that suggested that they are not interchangeable within S-D logic
(Harrison & Waite, 2015; Hilton & Hughes, 2013; Vargo & Lusch, 2008). However, in line with
 JOURNAL OF MARKETING MANAGEMENT 981

Ranjan and Read (2016), the findings of this study suggest that VCC should incorporate both
COPR and VAIU in a healthcare context. Customers are primarily co-producers before they can
co-create something, particularly in the theoretical framework of S-D logic. COPR predomi­
nantly incorporates the idea of customers’ interaction during the service value chain and the
aspect of exchange, while VAIU suggests that value is always created through its utility and
capability. This conceptualisation bridges the theoretical chasm between the objectivity of
exchange and the phenomenology of the service logic by offering the much needed theore­
tical rebalancing of perspectives (Leroy et al., 2013). Further, Eggert et al. (2018) and Sheth
(2019) evaluated customer value from the value-in-exchange to VAIU and also acknowledged
the scope of customers’ value proposition when the value is co-created between supplier and
customer. Our findings reinforce the argument that value is transformed from a proposition
into perception by the customer and, therefore, COPR, through resource integration, is integral
to ‘value-in-use’, and will constitute a significant element of the VCC in S-D logic (Hilton &
Hughes, 2013). This finding certainly aids in minimising the ambiguity that exists around the
conceptualisation of VCC.
Our research findings respond to the call for research by Nahi (2016), who suggested
that research on VCC should be conducted in the context of the BoP market in order to
explore its benefits of engaging a broad group of co-creators in low-income communities.
Moreover, this research endeavour should also address the research call by Neghina et al.
(2017), who suggested that the differences in the type and length of relationships that
users can expect in various service contexts, such as healthcare, may influence their
motives to co-create. As in these cases an ongoing relationship plays a pivotal role for
VCC, and due to the need for joint decision-making, relating motives will play an instru­
mental role. This finding has developed and empirically tested the model where VCC is
taking place through the joint decision-making of the service provider and users.
The application of digital healthcare in achieving health-related objectives has received
serious research attention over the years. However, our knowledge is limited with respect to
value co-creation. To our knowledge, this is a pioneering study which has examined VCC in the
context of mHealth, that has been shown to enhance the overall quality of life of BoP
customers, using the theoretical framework of S-D logic. This bears immense importance as
the findings of this study establishes the phenomena of VCC at the BoP level, where access to
modern technology is very limited. However, as this study shows, VCC occurs at the BoP level
because these customers are keen to and are capable of utilising the most modern technol­
ogies in smartphones to enhance their quality of life. This study has addressed the critical issue
of how VCC influences quality of life, since customers are always co-producers of value, as they
interact, share information and mobilise resources. Along with the concept of co-production,
value-in-use is also an important factor for value co-creation, even for the BoP customers, since
they value experience, personalisation and privacy in the overall context of VCC. Consequently,
the customers are embedded in the service co-creation and delivery process and eventually
are responsible for value addition in the process. Therefore, both the dimensions of VCC (e.g.
co-production and value-in-use) play a key role in co-creating value. This is an essential
contribution considering the application of S-D logic in the case of VCC for the BoP market,
since service delivery is not only confined to human interaction. An important contribution of
this study for BoP customers is that it extends and validates empirically a parsimonious, yet
comprehensive, model that illustrates how the dimensions of VCC (co-production and value-in
-use) enhance customers’ empowerment and overall quality of life. Due to the advent of the
982 S. AKTER ET AL.

digital platform, customers now interact with devices and systems (e.g., mobile platforms,
online) for service co-creation and delivery.
In addition to S-D logic, consumer culture theory (CCT) revolves around the relationship
among the consumers’ individual and collective identities, experiences, cultural orientations,
and the nature and dynamics of the sociological categories through and across which these
cultural dynamics are enacted and inflected (Arnould & Thompson, 2005). CCT comple­
ments the theoretical discussion of S-D logic by focusing on consumer value co-creation
processes (Healy & McDonagh, 2013; Payne et al., 2009). Furthermore, health-related ser­
vices are not uncommon to the BoP customers; however, adopting a digital platform to
access the health services would provide an affordable, convenient and innovative means to
the consumer due to its relative advantage, trustworthiness and performance. Overall, the
combination of these two theoretical frames have solidified the argument of VCC in the case
of the BoP market in a developing country context and would emphasise a more magni­
ficent collaborative co-creation between service providers and consumer.
This study’s findings contribute to the natural alliance of S-D Logic and CCT (Arnould, 2006;
Pongsakornrungsilp, 2010) by incorporating its insights about VCC. Moreover, the findings
have also contributed to an important issue of CCT and S-D logic, which is to understand how
and why consumers consume (Healy & McDonagh, 2013). Indeed, a combination of the two
theoretical paradigms to examine VCC dynamics have substantial implications for under­
standing continuance intentions and the quality of life of BoP customers.
Overall, the findings of this study discusses the role of VCC for digital health services which
has extended our knowledge of the extant literature (Frow et al., 2016; Verma et al., 2012; Zhao
et al., 2015). However, the findings of the study provide theoretical answers to how the
customers of a developing country, living at the lower echelon of the economic hierarchy,
obtain health services and therefore improve their standard of living. This finding is essential as
VCC has not only been found empirically crucial for empowering the BoP market but also for
impacting their lifestyle in the digital landscape. The relationship between VCC and customer
empowerment is prevalent in extant literature (Shin et al., 2019); however, empowering BoP
customers to access health services and thereby enhance their standard of living is a new arena
that this study has empirically developed and established. Moreover, the findings also con­
firmed the mediating role of empowerment in achieving a good quality of life.

Managerial implications
More than 1.6 billion people live in fragile settings where demand of health services, linked
with the prolonged and inadequate capacity of essential health services, impersonates a vital
challenge to global health (United-Nations, 2020). It is possible to turn this situation around
though with advances in technology, which have influenced almost every part of everyday life.
As such, the customers of the BoP market in a developing country are now being invited to
interact with the health service providers using digitally enabled technologies. The findings
demonstrate that the relative advantage of interactive-digital healthcare, its utility, and
functionality play an important role in creating value. The findings indicate that BoP customers,
despite their socio-economic limitations, are habituated to participate and interact with most
modern digital technologies.
In this study, we investigated people’s experience through ‘Shastho Batayon’, which is
a 24/7 online health service platform providing medical consultations and advice from
 JOURNAL OF MARKETING MANAGEMENT 983

registered physicians in Bangladesh. Thus, the study context and the purposeful investi­
gation shed light on the United Nation’s third most prioritised goal, ‘Good health and
well-being’ (https://www.undp.org). Such findings could be insightful for policymakers
and other organisations and encourage them to adopt such a platform for delivering
other life-enhancing services, such as education and employment, for this group of
people. The activities will likely be able to enhance a country’s economic growth. The
‘Shastho Batayon’ can also increase its service periphery by creating more co-creation
avenues. From a macro-environmental perspective, adopting a multi-stakeholder
approach is crucial for developing and delivering such a digitally enabled technology.

Limitations and future research

The present study is not beyond limitations. First, the study sample consisted of active
subscribers of the platform, which could lead to self-selection bias. The consumers who
have different experiences with this platform could have different perceptions of VCC. This
suggests that the findings of the present study should be interpreted as only explaining the
VCC for current users. Second, in this study, we adopted a quantitative research strategy.
Future research could use a qualitative approach such as focus groups, in-depth interviews and
other qualitative strategies which could unearth additional factors and shed light on the issue
from a different perspective. Third, although the study was conducted in both rural and urban
areas for the final sample consisting of 210 responses, a larger sample size could provide
a more detailed point of view. Fourth, through this platform, a patient’s overall experience with
medical service relies on several other factors such as user-friendliness of the platform,
availability of medicines in nearby shops, and strength of the mobile/internet connection.
Moreover, the users’ financial situation could also moderate the relationship between VCC,
customer empowerment and quality of life which could be addressed in future studies. Finally,
we adopted the measurement of Ranjan and Read (2016), which considered COPR and VAIU as
its two components, which deviates from other existing thoughts. Future studies could
address this deviation.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Notes on contributors
Shahriar Akteris an Associate Professor of Digital Marketing, Analytics & Innovation at the School of
Business, University of Wollongong, Australia. He was awarded his PhD from the University of New
South Wales (UNSW) Business School Australia, with a doctoral fellowship in research methods from
the University of Oxford. He has published in leading business and management journals with a
Google Scholar h-Index of 30 and around 7,000 citations. He was also the Guest Editor of the Journal
of Strategic Marketing, International Journal of Operations and Production Management, Electronic
Markets, Journal of Organizational and End User Computing, International Journal of Information
Management for their special issues on various management research.
Mujahid Mohiuddin Babu works as an Assistant Professor in Marketing in Coventry University, UK. His
research interest lies in the areas of firms’ strategic orientation, value creation, customer engagement,
Technology in marketing, Big data analytics capability and its application employee engagement. His
984 S. AKTER ET AL.

research works have been presented and published in various leading Journals and conferences of busi­
ness and marketing such as Industrial Marketing Management, Journal of Business Research,Technological
Forecasting and Social Change, Journal of Marketing Management, Information Systems Frontiers, Strategic
Change, Information Systems Management , Annals of Operation Research, Production Planning and
Control, Journal of Strategic Marketing, EMAC, Academy of Marketing, American Marketing Association
(AMA) and Academy of Marketing Science (AMS). His work has received Best Paper Award at the Academy
of Marketing Conference 2017.
Md Afnan Hossainis a Senior Lecturer at the Department of Marketing and International Business,
School of Business and Economics, North South University, Bangladesh, and a Ph.D. candidate at the
School of Business, University of Wollongong, Australia. He has demonstrated excellence in research
by publishing many research papers in top-tier journals (e.g., Scimago Q1 journals). He is also an
active reviewer of some reputed international journals such as Annals of Operations Research,
Journal of Strategic Marketing, International Journal of Information Management, Marketing
Intelligence and Planning, etc.
Umme Hani is a PhD candidate at the School of Business, University of Wollongong, Australia. She
has completed her Masters in Marketing from the Sydney Graduate School of Management (SGSM)
at the University of Western Sydney, Australia. Her primary research interests are relationship
quality, service quality, and social banking. She has published her work in the Journal of Business
Research, Journal of Service Research, Journal of Marketing Management, International Journal of
Information Management, Technology Forecasting and Social Change, Behaviour & Information
Technology, and International Journal of Marketing Studies.

ORCID
Shahriar Akter http://orcid.org/0000-0002-2050-9985
Mujahid Mohiuddin Babu http://orcid.org/0000-0001-6952-0723
Md Afnan Hossain http://orcid.org/0000-0003-2954-1823
Umme Hani http://orcid.org/0000-0001-6396-469X

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