The Conflicting Conventions of Care: Transformative Service as Justice and Agape

Abstract

In this study, we examine the conflicts and unintended consequences that arise from the diverse social conventions constituting a transformative service. We draw on convention theory and an ethnographic study to interpret a community-based palliative care initiative in Kerala (India) as a transformative service system. We contribute to transformative service research by developing a dialectical transformative service system framework that is a synthesis of the calculative conflict-ridden regime of justice and the noncalculative regime of agape based on love. In this framework, the calculative regime of justice has civic conventions at its core and industrial, inspired, market, domestic, and fame conventions as ancillaries. While the regime of justice is associated with the undesired, unintended consequence of conflicts, the regime of agape constitutes a desirable unintended consequence. Our framework provides a microlevel understanding of disputes and their reconciliation, advances a diffused understanding of worth that ruptures the binary of legitimate or illegitimate actions, and delineates the significance of morality. Our study also contributes by explaining agape’s role in transformative service, particularly in health and caregiving.

Keywords

agape conflicts convention theory justice palliative care transformative service research Kerala

Accomplishing transformative service is often a collective endeavor that involves multiple collaborating actors (Anderson and Ostrom 2015; Anderson et al. 2013, 2016; Baron et al. 2018; Blocker and Barrios 2015; Skålén, Aal, and Edvardsson 2015). Transformative service research (TSR) primarily draws on service-dominant (S-D) logic to examine service systems (or ecosystems) that integrate resources and cocreate value coordinated through shared institutions (Vargo and Lusch 2004, 2016). However, the S-D logic, which emphasizes individual benefits, resource integration, and value cocreation, advances a market-based understanding of a service system. Drawing on convention theory, or the sociology of conventions, we show the limitations of S-D logic in informing transformative service and offer an alternative dialectical framework that highlights how regimes of justice and agape accomplish transformative service.

Convention theory focuses on common understandings among people that underpin coordinated and collaborative actions since people negotiate the complex, conflicting demands of existence in contemporary societies based on shared conventions (Boltanski and Thévenot 1999). Specifically, we draw on two broad approaches to coordination: the regimes of justice and agape (Boltanski 2012; Boltanski and Thévenot 2006). A regime of justice consists of diverse social conventions—such as professional standards, civic duties, traditions, or markets—which individuals draw on to justify their actions on moral grounds. This regime of justice is based on equivalence, which people calculate using available conventions. Actors may enact conflicting conventions in various contexts. For example, actors may draw on conflicting conventions—such as environmental conventions of sustainability, industrial conventions of regulations and standards, and market conventions that value pricing and monetization—to justify products and services in an environmentally sensitive setting such as the upstream petroleum industry (Finch, Geiger, and Harkness 2017). In this vein, Patriotta, Gond, and Schultz (2011) have documented how stakeholders may deploy plural competing industrial, civic, and market conventions in responding to a nuclear accident. In contrast to such calculations and conflicts, people cooperate out of love and act selflessly in a regime of agape. Therefore, the calculative equivalence and reciprocal expectations that are foundational to justice are set aside in a regime of agape (Boltanski 2012; Boltanski and Thévenot 1999). Agape can create close bonds between service providers and recipients. Indeed, agape can be a key element in creating solidarities in social movements and community initiatives (Summers-Effler 2007).

With its focus on individual benefits, resource integration, and value cocreation, S-D logic emphasizes the market convention of the regime of justice in which self-interest, competition, and detached social relationships are key features (Boltanski and Thévenot 2006). Thus far, the TSR informed by S-D logic engages with justice within the conventions of markets. As a result, transformative themes such as poverty reduction, access to social services, service literacy, and vulnerable consumers (Anderson and Ostrom 2015; Anderson et al. 2013) have been investigated from the perspective of market conventions by attending to how resources are integrated and value is cocreated. We argue that by emphasizing S-D logic, TSR has been monochromatic. In contrast, a transformative initiative requires a broad interface reflective of society and its various conflicts.

While the quest for justice in the market world privileged within S-D logic can be transformative, we foreground other conventions of worth. Social actors and transformative service initiatives often have to deal with the unintended consequences of conflicts between multiple conventions in a regime of justice and their reconciliation. For example, Batifoulier, Da Silva, and Duchesne (2019) show that the French social security system has shifted over time from a dominant anticapitalist convention to a compromise between solidaristic and liberal conventions. In another example, Sreekumar and Varman (2019) show that poor migrants negotiate the conflicting demands of conventions of traditions and commodified relationships to resist dominant consumer acculturation. Such conflicts between conventions are underexamined in the extant TSR informed by S-D logic (Laamanen and Skålén 2015; Skålén, Aal, and Edvardsson 2015). Moreover, we highlight the importance of the regime of agape, a neglected facet of transformative service for a vulnerable group.

We examine conflicting care conventions in a community palliative care service system in Kerala, India (henceforth the community model). Palliative care is an approach that improves the quality of life of patients and their families facing life-threatening illnesses through medical, psychosocial, and spiritual support (World Health Organization 2020). Across the world, professional teams of nurses, physicians, and social workers operating through hospitals and hospices deliver palliative care. With one sixth of the world’s population, India has less than 2% palliative care coverage, and most states have no palliative care awareness or facilities (Rajagopal 2015). In contrast, the state of Kerala provides palliative care to more than 60% of its population through the community model. The community model has transformed patients’ and families’ lives by offering free home-based care encompassing financial, social, emotional, medical, rehabilitation, and bereavement support (Vijay, Monin, and Kulkarni 2020). At the community level, it has produced cascading effects from the palliative care domain into overlapping fields such as geriatric care and mental health. At the institutional level, in response to community mobilization and advocacy, public health organizations collaborate with community organizations to provide home care (Kumar 2013). Therefore, we consider Kerala’s community palliative care service system as a fertile ground for examining transformative service and its unintended consequences.

We develop a dialectical transformative service system framework that is a synthesis of the calculative conflict-ridden regime of justice and the noncalculative regime of agape. By developing the framework, we contribute to TSR in three ways. First, we illustrate how a transformative service inheres a regime of justice with diverse social conventions. While TSR has thus far primarily drawn on institutional theory-informed S-D logic, our framework broadens TSR to include the role of conventions. In our framework, the transformative service is constituted by civic conventions at its core and industrial, inspired, market, domestic, and fame conventions as ancillaries. We identify conflicts arising as unintended consequences of the diverse social conventions constituting the transformative service. Second, we develop a richer conceptualization of transformative service by offering a microlevel understanding of disputes and their reconciliation that transcends the binary of legitimate and illegitimate actions, which is central to theorization based on the understanding of institutions. By attending to the microlevel, we also develop a diffused and context-specific understanding of worth that foregrounds the significance of morality. Third, our framework contributes to TSR by highlighting the regime of agape in a community care setting. In so doing, we transcend the grammar of calculation and exchange to open up an understanding of service based on a sense of solidarity and love.

Theoretical Considerations

In this section, we review TSR with a focus on health care. We then draw on the French convention school to delineate how diverse conventions of justice with conflicting demands and principles come together in transformative service. Finally, we discuss the regime of agape that is central to the community model.

TSR on Health Care

While some researchers have delineated diverse social influences beyond the market logic that underpin transformative service (e.g., Baron et al. 2018; Blocker and Barrios 2015; Skålén, Aal, and Edvardsson 2015), TSR has been lopsidedly informed by S-D logic that highlights exchange through markets within service systems. S-D logic adheres to a research tradition that emphasizes how firms and managers integrate and use resources to create superior market value and secure sustained competitive advantage (Barney 1991; Vargo and Lusch 2004). According to S-D logic, the common purpose of market actors is value cocreation and resource integration through “service-for-service exchange,” with a calculative expectation of exchanging benefits (Vargo and Lusch 2016). Notably, S-D logic has a broad view of resources, and two of its “fundamental premises” suggest that “All social and economic actors are resource integrators” and “Value is co-created by multiple actors, always including the beneficiary” (Vargo and Lusch 2016, p. 8). Hence, S-D logic focuses not only on firms’ and managers’ strategic benefits, but it also extends the resource-based market logic to all types of relations and service systems. Accordingly, both economic (e.g., firms and managers) and social actors (e.g., families and their members; Vargo, Akaka, and Yi 2010) are resource integrators operating with a calculative market logic (Fougère and Skålén 2013).

Several empirical TSR studies, especially within health care, have drawn on S-D logic to attend to resource integration, value cocreation, and service systems, thus remaining confined to the market logic. In a key study examining cancer patients’ value cocreation, McColl-Kennedy et al. (2012) identify five “customer value co-creation practice styles” in which patients’ active involvement secures resource integration. This understanding of patients as benefit seeking, resource integrating, and cocreating customers implies a market logic. Similarly, Frow et al. (2016) studied health care as a service ecosystem of resource integration processes “to develop a typology of co-creation practices” (p. 24).

Sweeney, Danaher, and McColl-Kennedy (2015) elaborate on McColl-Kennedy et al.’s (2012) work to suggest that the more effort patients put into value cocreation, the more satisfied they are. Presuming that patients as customers need to exert efforts to receive health care services underscores a transactional market logic. Furthermore, Anderson et al. (2016) point to market logic when they attend to resource integration and value cocreation in health care under a regime of responsibilization. They identify three resource-integrating practices: accessing, managing, and appropriating and contribute to TSR “by identifying resource-integration practices that a responsibilized consumer must undertake” (Anderson et al. 2016, p. 263). This S-D logic-based approach portrays patients as calculative consumers who must take responsibility for their health care by enacting practices, as in any market. By focusing on value cocreation, resource integration, and service systems, this research, in line with several other health care studies (e.g., Anderson, Nasr, and Rayburn 2018; Breidbach, Antons, and Salge 2016; Danaher and Gallan 2016; Davey and Grönroos 2019; Frow et al. 2016; McColl-Kennedy, Cheung, and Ferrier 2015; Sharma and Conduit 2016; Spanjol et al. 2015), frames transformative service as a calculative market regime emphasizing strategic benefit.

In summary, drawing on S-D logic, TSR has primarily understood transformative service, particularly in health care, from the market logic perspective. In the transformative service we examine, the market logic does not play a central role. Moreover, TSR on health care does not offer insights into the unintended consequences of conflicts that arise when actors follow multiple conventions, and there is a neglect of how these conflicts are resolved. We found that these issues were salient in Kerala’s community model. We now turn to convention theory to provide a broader conceptualization of transformative service.

Convention Theory

Convention theory examines how conventions constitute different evaluations or orders of worth underlying conflicting ways of life (Boltanski and Thévenot 2006). A convention is a publicly recognized interpretation and evaluation of a situation that offers an understanding of the common good (Batifoulier, Da Silva, and Duchesne 2019). Instead of assuming pregiven needs, resources, and evaluations, convention theory regards convention-based coordination as central to these ontologies from which institutions and values emerge (Diaz-Bone 2016). Conventions may have arbitrary origins but provide normative action frameworks (Al-Amoudi and Latsis 2014). For example, Bridson et al. (2017) explain how music fans do not support market conventions and locate artists in the inspired world. These music fans do not see the market world as authentic and thus label the musicians who follow commercial motives as “sellouts.”

Boltanski and Thévenot’s (2006) seminal writing on the sociology of conventions, “On Justification,” challenges sociological frameworks that reify social actions. Specifically, the authors depart from a Bourdieusian emphasis on habitus or dispositions or Durkheimian assumptions of collective reasoning based on group membership. Instead, convention theory adopts a fluid interpretation that foregrounds situations and pragmatism, which shape social actions. There is no single optimal convention for all situations or universal cognitive frameworks for all social actions (Diaz-Bone 2016). Convention theory assumes a plurality of possible ways to structure social coordination. While these regimes can include some strategic behaviors, they are rooted in the coherence, habits, morality, and procedural requirements of a social space (Al-Amoudi and Latsis 2014).

Conventions are not the same as institutional logics that are “socially constructed, historical patterns of material practices, assumptions, values, beliefs and rules” (Thornton and Ocasio 2008, p. 101). Institutional logics are ensembles of higher order meanings, values, norms, and rules that frame how actors make sense of the world and act in legitimate or illegitimate ways in different societal sectors (e.g., state, market, or family) or industries (Cloutier and Langley 2013; Thornton et al., 2012). The idea of logics derives from Durkheimian sociology, which assumes that rules are hierarchically organized, thereby allowing actors to draw on collective rationalities. Indeed, S-D logic draws on institutional theory to better understand resource integration and value cocreation in service systems (Vargo and Lusch 2016). Further, some TSR studies have uncovered how a service can be shaped by contestations between institutions and the practices they condition (Anderson et al. 2016; Baron et al. 2018). Convention theorists offer important insights to these conversations by highlighting that actors do not rely on collective rationalities all the time; all situations do not require an imperative of justification to the same degree, and criticisms are not always rejected via clear-cut argumentation (Boltanski and Thévenot 2006). Accordingly, there are proximate and intuitive ways of coordinating through different conventions (Boltanski and Thévenot 1999). Convention theory also rejects the assumption that social actors make sense of the world in a predetermined way, as dictated by a particular institutional logic. Instead, convention theory assumes that actors draw on elements from different worlds depending on their situations (Cloutier and Langley 2013), and conflicts and disputes inhere moral justifications. For example, Sreekumar and Varman (2019) show that poor Indian immigrants juggle with conflicting conventions depending on their situations. In the Middle East, these immigrants draw on the domestic world’s conventions to resist the dominant market-based consumption culture. However, back in India, the same lower-class return migrants turn to market-based conventions while using their savings from the Middle East to transform their social status and to challenge their low positions in the traditional domestic hierarchy. Similarly, stakeholders in a mobile health initiative may draw on conflicting calculations of the benefits of standardization, including industrial conventions emphasizing planning and efficiency, civic conventions stressing quality for all citizens, and market conventions highlighting monetization and insurance payments (Cappel and Kappler 2019).

Boltanski and Thévenot (1999) describe three regimes of coordination: justice, agape, and familiarity. In a regime of justice, the principle of equivalence is most salient, and it draws on orders of worth that are dependent on socially accepted conventions. In a regime of agape, persons actively cooperate out of a sense of love and abandon equivalence and calculations of reciprocal conduct. In a regime of familiarity, a person is intimately engaged with familiar surroundings and people and follows customs specific to that arena, which are not available to any unfamiliar observer (Boltanski and Thévenot 1999). In this research, we found that a regime of justification and a regime of agape were salient in community palliative care. While this model emplaces care in patients’ communities, caregivers may not be familiar with patients and families. Hence, a regime of familiarity was not as relevant to our context. We explain the regimes of justice and agape in the following sections.

The regime of justice

Conflicting worldviews can often create disputes among individuals or groups. Actors involved in a dispute must adopt an “imperative of justification” by following the rules of acceptability to come to a resolution (Boltanski and Thévenot 1999, p. 360). Justifications equate particular notions of worth located within a world into more generalized notions of the social good. At the heart of justice is the emphasis on equivalence of worth. Boltanski (2012) suggests that people’s agreement on calculations of worth is a condition for creating justice. While individuals may resolve disputes through an agreed-upon principle of equivalence, the contemporary world is comprised of competing principles of equivalence. Boltanski and Thévenot (2006) describe six common principles of equivalence with their attendant notions of worth: civic, market, industrial, domestic, inspired, and fame worlds (see Table 1). These principles of equivalence follow rules of acceptability or conventions characterized by different orders of worth.

Table 1.

Regime of Justification: Different Orders and Indicators of Worth.

Orders of Worth	Indicators of Worth
Civic	Collective interest, promoting solidarity, and furthering welfare of others
Industrial	Expertise, efficiency, and productivity
Inspired	Nonconformity, creativeness, and other worldliness
Domestic	Dutiful, traditional, and hierarchical
Market	Price, money, commercial success, and superior to competitors
Fame	Public recognition and public esteem

The civic world emphasizes collective interests, fairness, solidarity, and rule-governed behaviors (Thévenot 2001). In the civic world, a sovereign is created by the convergence of human will, as individuals give up particular interests, create solidarity, and work toward the common good (Boltanski and Thévenot 1999). This order of worth centers on collective persons governed by relations of equivalence. In this world, individuals attain worth by placing the collective ahead of their individual interests and forging solidarity. A worthy caregiver in this world, for example, rejects private gains and works for the collective good by collaborating with others and contributing to community health.

In contrast to the civic world, desires are shaped by self-interest in the market world. In this world, people compete for scarce resources to get ahead. Buyers, sellers, and competitors who engage in relations of self-interest populate this world. Here, people are detached from one another, and transactions shape their space of dependence. The worthy in this world can calculate and seize market opportunities (Boltanski and Thévenot 2006). For example, a worthy caregiver in the market world has commercial motivations, may seek to make private gains, and outperforms competitors to meet personal objectives. S-D logic’s emphasis on resource integration and strategic benefiting fits well with the market world.

The industrial world is constituted by “technological objects and scientific methods” (Boltanski and Thévenot 2006, p. 203). It is a world based on efficiency, and worth is measured through formal professional capabilities, performance, productivity, reliability, and predictability. The worthy person in this world is an expert. For example, a worthy caregiver, such as a physician or nurse in the industrial world, has standardized training, technical expertise, and qualifications to efficiently deliver health care. The relationships among experts in this world are effective when they are organized, measurable, and standardized (Boltanski and Thévenot 1999).

In the domestic world, worth depends on following traditions and a hierarchy of trust derived from personal interdependencies (Boltanski and Thévenot 2006). In this world, worth is assigned to a specific individual who is an insider. In our study of community palliative care, membership in a religious order is particularly salient. Worth is based on the intergenerational transfer of traditions and hierarchies and emphasizes duties, etiquettes, and maintaining ties. Worthy individuals in the domestic world are guided by traditions, such as those of a religious or familial nature, and are moved by a call for duty based on these preexisting structures to take responsibility for others who cohabit an order. Worthy caregivers, for example, follow traditions, maintain relations, and fulfill duties faithfully toward affiliated groups.

In the inspired world, the worthy know “how to recognize and welcome what is mysterious, imaginative, original, unspeakable, unnamable, ethereal, or invisible” (Boltanski and Thévenot 2006, p. 160). Here, the worthy are impelled by a higher cosmic order that makes them pursue desirable actions. Worth rests upon attaining a state of grace independent of reputational or financial recognition (Boltanski and Thévenot 1999). Accordingly, it can have many expressions such as creativity, artistic sensibility, and imagination. A worthy caregiver in this world disavows recognition or commercial gains and provides service for its intrinsic worth. For example, a physician following the inspired world’s conventions may shun a lucrative career to create an unconventional health initiative for the poor.

Finally, the world of fame is characterized by a relational order in which others ascribe worth to an individual. In this world, people desire recognition, seek public esteem, and crave respect. People achieve worth by becoming visible and recognized in a space where they can be seen and compared. For example, worthy caregivers in the world of fame are recognized and held in high esteem by the public for their services. In this world, a caregiver can cultivate recognition by using media and other public platforms that accord visibility. Hence, creating a public persona is of prime importance, and the banal is unworthy.

Convention theory attends to disputes in a given context. These conflicts can be internal to a world in which people notice flaws and violations of conventions (Boltanski and Thévenot 2006). Such conflicts are not major and can be resolved by improving the implementation of a world’s conventions. Challenges or tests arising in another world are more radical (Boltanski and Thévenot 1999). These conflicts arise because of different conventions and notions of worth that prevail in a social setting. People may forget these disputes or dismiss them as unfair because they are based on conventions stemming from another world. For example, the market world can reject disputes raised from the civic world as unfair because of contrarian conventions. However, these tests often cannot be negated, and disputes are not easily refuted. Such situations require reconciliation between worlds, which take the shape of compromises or the cohabitation of different conventions, changes to allow one world to dominate, or certain worlds becoming marginalized (Boltanski and Thévenot 2006). For example, if seen as justified in a setting, individuals can marginalize the market world’s conventions and replace them with the civic world’s conventions. Thus, conventions of different worlds lead to disputes that require reconciliations.

In sum, convention theory helps to facilitate understanding of different conventions of justice that cohabit a social space of collective endeavors for transformative service. The framework of conventions does not interpret collective endeavors as conflict-free activities. Instead, transformative arenas are fraught with people pursuing different orders of worth and conventions. Moreover, the same individual can pursue different orders of worth in different situations. Drawing on this reading, we analyze the role of different worlds with associated conventions under a regime of justice in shaping Kerala’s community palliative care.

The regime of agape

Some situations do not require the evaluation of justice and are outside the conflicting conventions described above. Boltanski (2012) suggests that agape as a form of love can be one such alternative to justice. Agape is a free gift that shuns equivalence; it is about detachment from worth and calculations that are central to justice. Agape does not contain desire, and it is sacrificial, unselfish, and gives freely (Belk and Coon 1993; Nygren 1953). As Boltanski (2012) explains, “persons in the state of agape neither hold onto things nor expect things” (p. 114). In articulating this view, Boltanski draws on Kierkegaard’s (1995) notion of love that is not a barter. Agape is not confined to specific spaces and a narrow circle of acquaintances. As Boltanski (2012) notes, “everyone in the state of agape gives to anyone he or she meets. But the one to whom the gift is addressed demands nothing since he or she sets aside the thought of desire” (p. 146). In agape, each person anticipates others’ needs, and those who have more give more, seeing the needs of those who benefit as their own needs. Here, others’ judgments are of little consideration, and as a result, agape abolishes justice (Nygren 1953). Hence, agape is inconsistent with S-D logic’s notion that actors operate with the calculative expectation of exchanging benefits.

Drawing on the work of Arendt (1958), Boltanski (2012) explains that the regime of agape resolves offenses by not punishing or forgiving people as justice would require, but by forgetting and dismissing such acts in the spirit of “life must go on” (p. 115). Agape rejects the past as a temporality that requires calculations of justice and embraces the present as the only temporal orientation. As Kierkegaard (1995) observes, “there must be eternal vigilance, early and late, so that love never begins to dwell on itself, or to compare itself with love in other people, or to compare itself with deeds it has accomplished” (p. 179). Hence, agape is not interactionist in which people’s anticipations of others’ responses would shape their behaviors (Boltanski 2012). Moreover, agape is often tacit and not visible to an outsider unless one interacts with insiders to understand their actions.

Finally, in the contemporary world, it is difficult to find pure regimes of agape from which calculations are entirely absent. As a result, agape coexists with regimes of justice. When people become calculative and enter into disputes, they move toward justice and exit the regime of agape. With such a shift, actions are scrutinized, and calculations of equivalence become dominant. Similarly, a person can shift from a regime of justice, gradually abandoning calculations and surrendering to agape (Boltanski 2012). In the subsequent sections, we examine the dynamics between different conventions and regimes of coordination in Kerala’s community palliative care system.

Research Context and Methods

Kerala, located in Southwest India with a long coastline along the Arabian Sea, comprises about 1% of India’s landmass and 3% of India’s population (approximately 35 million). Kerala’s community palliative care started in 1993 as a doctor-run pain clinic at the Kozhikode Medical College (North Kerala) established to provide pain relief for terminally ill cancer patients. Besides a nascent palliative care clinic at Thiruvananthapuram (South Kerala), Kerala had no other facility at that point in time. Kozhikode’s resource-starved clinic drew on volunteers for administrative support. Volunteer engagement intensified with exponentially increasing patient numbers and a growing realization of the need for home care. Subsequently, early stakeholders experimented with different service delivery prototypes, eventually stabilizing a model of networked but financially and operationally autonomous community organizations. In this model, the fulcrum of caregiving, fundraising, and ‘decision-making’ shifted from a few medical professionals to thousands of community volunteers. Table 2 specifies the key milestones in the community palliative care model’s development as a transformative service.

Table 2.

Milestones in the Evolution of the Kerala Community Model as a Transformative Service System.

Year	Event	Service System Outcome
1993	Founding of first pain clinic by two doctors and three volunteers in Kozhikode City (North Kerala)	Initiation of pain relief for terminally ill patients
1995	Founding of first satellite clinic at Manjeri	Experimental hub-and-spoke model taking care closer to patients’ homes
1998	Founding of first community organization at Nilambur	Volunteer-run organizations that undertake volunteer- and nurse-driven home care at community level, with physicians providing need-based support
2001	Formation of Malappuram Initiative in Palliative Care	Governing body for different community organizations to coordinate resource allocation and create common practice framework
2004	Commencement of Pariraksha—pilot partnership between Malappuram community organization and local self-governing institutions	Partnership with formal state institutions
2008	Approximately 83 palliative organizations in Kerala of 139 in all of India Kerala state government announces first palliative care policy, mandating state-funded primary health centers to train medical professionals in palliative care and stock morphine; collaboration with community organizations as a way forward	Cross-sector collaboration between community organizations and state health agencies First pain and palliative care policy in Asia
2015	State health organizations become dominant care providers in terms of numbers and expenditure	State health organizations adopt home care model involving volunteers or collaborations with community organizations
2019	Revised state pain and palliative care policy	Greater integration of community model into public health system

Volunteers come from heterogeneous social groups of class, gender, religion, and caste and work with patients in their neighboring communities. Volunteers typically are the patients’ proximate and frequent contact points. After receiving training, volunteers go door-to-door in neighborhoods to identify patients; visit families regularly; identify the psychosocial, financial, or emotional aspects of care; and serve as the voice for the patient’s and the family’s needs. Nurses constitute the first level of medical support and provide routine home care with volunteers. Physicians, as the most limited health care resource, conduct home care depending on the case criticality and complexity. Community organizations conduct “outpatient days” for patients’ consultations with physicians. The better-resourced organizations have in-patient facilities (e.g., 10 beds) for patients who needed critical medical attention or a change from their homes. Typically, community organizations pay physicians and nurses for their services, albeit a nominal amount compared to public- or private-sector service.¹ While physicians and nurses address medical symptoms, volunteers alleviate social suffering and collectively improve patients’ and families’ well-being (Kumar 2020).

As community organizations proliferated across Kerala, the scope of care expanded from advanced cancer to early-stage cancer; HIV/AIDS; chronic renal, respiratory, and cardiovascular diseases; mental health; and geriatric conditions (Vijay and Monin 2018). In 2008, responding to community organizations’ advocacy, the Government of Kerala introduced a policy integrating palliative care into the public health system. Currently, there are over 230 community organizations. More than 900 panchayats (village-level local self-governing institutions) designate at least one nurse for palliative care at each primary health center (PHC). Community organizations work formally or informally with the public health system (Kumar 2020; Vijay, Whitelaw, and Clark 2020). The Kerala palliative care system has more services than the rest of India put together.

Data Collection

This study is based on ethnographic fieldwork (Spradley 1980) on Kerala’s community palliative care system over 10 years between 2009 and 2019. During this period, the second author conducted fieldwork at 22 community organizations that were purposively sampled across the geography and founding period. To investigate routine activities, she participated in over 40 home care days (each home care day typically covered four to five patients) with nurses, doctors, and volunteers, during which she observed caregivers’² interactions with patients and families. She attended service review meetings, participated in training sessions for volunteers, and observed how the volunteers introduced new care practices based on patient interactions. Additionally, she participated in international and national palliative care events, which furthered comparative insights into the Kerala model’s distinctive features vis-à-vis other service systems. Thus, her engagement with the palliative care sector was ongoing and deep. In 2019, the first and second authors jointly visited four community organizations to observe the caregivers’ interactions and relationships in such care settings. Field notes and researcher diaries were written either during or directly after the participant observation.

To understand the transformative nature of community palliative care, we conducted 145 in-depth interviews (McCracken 1988) ranging from 30 minutes to 3 hours over a 10-year period. Most interviews were in Malayalam. Fourteen interviews with physicians and state officials were conducted in English. We audio-recorded the interviews, and the audio files were translated into English and transcribed. Participants included physicians, nurses, volunteers, patients, family members, journalists, and government officials. Interviews with caregivers typically followed a narrative approach, beginning with questions about the participant’s background and then moving on to motivations to engage in palliative care, organizational practices, shifts in organization over time, and the impact of palliative care. In the last phase, we focused explicitly on caregivers’ life narratives, backgrounds, ideologies, religious or political commitments, articulations of caregiving, and interactions with other caregivers, patients, and families. We also curated a data set of 1,157 secondary data sources (e.g., newspaper data, journal articles, and organizational documents) published between 1993 and 2020, which helped reconstruct milestones, triangulate the data, and deepen our insights from the interviews and field visits.

Data Analysis

Over the years of fieldwork, we came across conventions from different worlds and witnessed agape in various forms. Our subsequent reading of convention theory gave us a conceptual understanding of the regimes of justice and agape, which guided the data collection and analysis in 2019. Our analysis involved three key stages and used an abductive approach (Dubois and Gadde 2002). First, drawing on Boltanski and Thévenot (2006), we started with an initial analytical framework based on convention theory, which was particularly relevant because the community model comprised disparate groups and diverse situations. We coded all passages—in a sentence or paragraph—corresponding to the “orders of worth” actors mobilized in their justifications for participation. Table 3 provides the semantic markers for each common world and illustrations of the coding process (cf. Patriotta, Gond, and Schultz 2011).

Table 3.

Semantic Markers of the Common Worlds and Illustrative Quotes.

Common World	Semantic Marker	Illustrative Quotes
Core
Civic	Collective welfare, democracy, rights, participation, and fairness; “Taking office,” representative	▪ Development of community-led projects fundamentally involves the empowerment of the local community…. By organizing and mobilizing, communities can be empowered to achieve the social and political changes needed to address their powerlessness. (Kumar 2020, secondary data) ▪ The patient is not only the responsibility of their houses. He is the responsibility of that community. The community has to intervene for the patient. This duty is done by palliative care volunteers. (Philip et al. 2019, secondary data)
Ancillary
Industrial	Technical efficiency, competence, reliability, and productivity	▪ Because the complexity, scope and coverage of care differ at different levels of services, healthcare providers working at different levels need different types of training…. Some recent developments are going to bring changes in the education and training scenario and credibility to palliative care as a specialty in India. (Venkateswaran and Palat 2012, secondary data) ▪ There should be a protocol based on what a nurse, doctor, volunteer, and family carer can do. If there is a protocol, everybody will know that this is to be done, or this shouldn’t be done. (Lisa, physician, interview)
Inspired	Nonconformity, creativity, passion, vision, idea, and intuition	▪ I joined in 2006, and I have been here for so long. There are so many job opportunities in hospitals. If I go to the private sector, I would get 3–4 times the money. Many ask me about it. I feel happy working here. I am unable to forget my experiences. We have to be useful to patients who are in distress. Hospitals see different patients, but not these types of patients. It has to come from within the nurses or doctors to work for such patients, help such people, and support them. (Gita, nurse, interview) ▪ I have totally changed in my life. If I get free time, I spend it here. I don’t go out anywhere else or roam around with my friends. If I do go out, I will be thinking about my patients. During my [undergraduate] degree, it was like I went home, to college, and then out with friends. Now, patients here are my friends. It has become a habit. (Haneef, volunteer, interview)
Domestic	Tradition, rule of etiquette, duty, relationships, trustworthiness, faith, rank, and title	▪ Islam as a religion asks me to do charity work. God has instructed us to help others. This society and people are my responsibility, and it is my duty to serve them. It is a very personal thing. I am a believer and have the faith that I will be rewarded for my actions. (Abdul, volunteer, interview) ▪ We have all religions here. What we learn from childhood is that if your neighbor is hungry, and you are having food, then you are not a Muslim; that is what Islam says. In the Hindu religion, it is “Lokāḥ Samastāḥ Sukhino Bhavantu” [Let the entire world be happy]. Christianity says love your neighbor like yourself. All three religions say the same thing: help others. (Ashraf, volunteer, interview)
Market	Competition, salability, self-interest, and money	▪ It is the corporate outlook now. When it does not become lucrative, people don’t stay. Nobody would be ready to work for a lower salary when they are young. (Arth, physician, interview) ▪ Some are reluctant to come, but a few come in because they expect something out of this. They want certificates and money when they work here. (Raj, student volunteer, interview)
Fame	Reputation, recognition, and public attention	▪ We have Bipin, and he sings very well. But nobody knows him. So, in the last camp, we promoted him. (Rajith, student volunteer, interview) ▪ The other day, I went to give a small talk in a [local] college. As I entered, at least 20–25 girls came to me and said, “Uncle, you are here,” because they had seen me in palliative care. (Gopalakrishnan, volunteer, interview)

Certain accounts referred to multiple, intersecting worlds. Thus, in our second stage, we attended to conflicts and how they were resolved. Finally, based on an iterative reading of the data and literature, we mapped Boltanski’s (2012) conceptualization of agape to data that evidenced participant accounts of “unbounded care and love” and a “suspension of calculation.” We draw on this analysis to present our findings in the next section. We use pseudonyms to maintain participants’ anonymity, except in cases of explicit consent and when participants’ names and opinions are available in the public domain.

Findings

Our findings show that Kerala’s community palliative care constituted a transformative health care service in which diverse conventions came together under a regime of justice. We also show that a regime of agape is central to such a transformative service. We derive a framework of a transformative service system (see Figure 1) based on our findings as they are interpreted through the lens of convention theory (Boltanski 2012; Boltanski and Thévenot 1999, 2006).

Figure 1.

Framework of transformative service system.

The Regime of Justice in the Community Model

The regime of justice is characterized by a distinction between core and ancillary conventions (see Figure 1). The civic world’s conventions constitute the inner core of community palliative care. The outer conventions, which we see as ancillary but not insignificant, are made up of transactional, marginal, or nascent care engagements in the industrial, inspired, domestic, market, and fame worlds.

The core convention of the community model

The civic world

The core constitutive feature of the community model is the civic world. As explained in the research context, caregivers from diverse backgrounds coordinate to deliver community-based care. This model draws on civic conventions in which worth is assigned to collectives that occupy public space, where aspirations anchor around civil and political rights and participation (Boltanski and Thévenot 2006). In the civic world’s defining situations, caregivers commit to solidarity, work in the spirit of a common good, give to society, and alleviate public suffering. The civic world of community palliative care entails mobilizing volunteers, spreading awareness, microfundraising within communities to create ownership, and enlisting support from other institutions.

Anil Paleri was one of the physicians who worked with the first Kozhikode palliative care clinic and participated in the transition to community care. Paleri explained:

Once these centers started working independently, it was up to them. Raising funds…everything. The feedback from the community also goes back to the center. We made sure that we did things in a good way, and all the benefits went to the community. This has been a motivator for the people to work. Whatever they do, they get an immediate positive response from the community.

Thus, community organizations became sites of solidarity between the medical professionals and “the people” as they collectively provided palliative care. Some of Kerala’s palliative care physicians were instrumental in furthering the civic world’s conventions through their participation and public advocacy. Suresh Kumar and M. R. Rajagopal, both anesthetists at the Kozhikode Medical College, cofounded the first pain clinic and worked with volunteers to crucially shape community participation. M. R. Rajagopal spearheaded the advocacy for morphine as a pain reliever, challenging the prevailing Narcotics and Psychotropic Substances (NDPS) Act that thwarted its distribution (Rajagopal and Joranson 2007). This civic action resulted in the NDPS Act’s amendment, which eased drug distribution to community organizations and health centers.

Caregivers included community members, such as farmers or bus drivers, with primary or secondary education. They articulated a moral responsibility to participate alongside medical professionals in care delivery. For example, Unni, an autorickshaw driver who volunteered, shared the moral imperative that draws on the civic world:

We give patients and families relief and care. We can’t do this in a day or two. We visit for several days. This gives them the belief that we are there for them. We try and reduce whatever pain and sorrow the patient has. We listen to them patiently, understand their sorrows, and do whatever we can to help them in our own ways. The patients may not admit that they have not taken medicines or food; we need to understand that situation. We may help with their children’s education. The involvement of volunteers is essential. There might be a shortage of nurses and doctors, but area-wise, volunteers do most things.

Thus, volunteers like Unni work in solidarity with medical professionals, patients, and families (“we are there for them”). Another volunteer, Satya, was a retired school teacher and core committee member of the Kozhikode community organization. Satya was from a low-income family, and his mother was comatose at the end-of-life period and received free palliative care from the community organization. Through this experience, he became aware of the civic world’s collective possibilities, which motivated him to volunteer. He told us, “Once I started working, I realized I could care for others as well, not just for my mother. I try to spend a maximum amount of time on this. As human beings, we should help others.” Indebted for the care his mother received, Satya espoused civic conventions and located worth in collective interests and social unity. He had engaged in numerous civic and political activities, including volunteering during his undergraduate days, working with a literacy campaign in the 1980s, and volunteering in palliative care for over 9 years.

Unni and Satya struggled with socioeconomic inequities but were committed to civic and political participation in community care as expressions of justice to challenge inequities. In contrast to Unni’s and Satya’s impoverished financial backgrounds, Madhavan, from a middle-class family, engaged in this civic world after retirement. Having spent his professional life working in a multinational conglomerate overseas, he wished to “give something back to society” after retirement. Madhavan noted:

That was my passion while working. I wanted to work with an NGO [Non-Governmental Organization]. I had been earning for a long time, and at some point in time, you have to give something back to society. Palliative care is the need of the day. We do everything free of cost. There is a need to help the needy. Not only the poor are in need; it can be anyone. We cannot live like this. You need the support of an entire group of people. That is what I meant by giving back to society—so my existence should benefit people living around me, not just myself.

For most of his life, Madhavan was located in the market and industrial worlds that ascribed worth to individuals’ desires (e.g., “earning”) and lifestyles. Now locating himself in the civic world, Madhavan articulated his worth in terms of subordinating his individual self-interests to the collective, which was organized to alleviate pain. As a subject in this civic world, Madhavan took office as the community organization’s vice-chairperson: “In this position, I can contribute and advise. I can do a lot of things.” The civic world’s morality materially manifests in holding office, taking responsibility, and being part of a collective. Here, the idea of justice in the civic world is calculative—having made money in the market and industrial worlds, volunteers like Madhavan believe that justice requires that one give back for the common good.

In sum, caregivers drew on notions of civic responsibility and social justice to describe their commitments and the nature of transformative service. While individuals calculate community caregiving as a form of reciprocal justice, it is infused with a civic order of worth and a moral imperative that offers an alternative to the market logic of buyers and sellers and the industrial logic of efficiency.

The ancillary conventions of the community model

The industrial world

In the industrial world, the worthy are professionals with expertise and those who emphasize an organization’s functionality, reliability, and operational performance (Boltanski and Thévenot 2006). The industrial world surfaces in situations where medical expertise is paramount. Although this world, with its emphasis on trained doctors and nurses, was dominant in the founding years (notably 1993–1997), it became ancillary to the civic world with the spread of the community model after 1998 (see Table 2). At an international seminar in 2004, Suresh Kumar reflected:

In this model [doctor-centric], there is no continuity of care…. We have been trying to work on this, and after a lot of deliberations, last year, in August 2001, we started a new program. It’s on a trial run in a small district, one of the poorest districts in Kerala, Malappuram, a district with a population of 4 million. It’s…called Neighborhood Network in Palliative Care (NNPC), aimed at training helpers and volunteers in the community and supporting them with trained professionals. (Kumar 2004 as quoted in Reynolds and Tansey 2004, p. 55)

Kumar’s account shows the shift from a doctor-centric model to the community model, which created neighborhood volunteer networks around patients’ homes. Mathews Numpeli, one of the early physicians pivotal to the work with community organizations, recollected:

First, in palliative care, they taught symptom management, psychological support, and social support. Then, it came to the second major stage, and some were involved for social service, and others for spiritual reasons. But now, all types of people can do it. Now, palliative care is a right.

Numpeli described the shift of the core of the community-based transformative service system from the conventions of the industrial world, to a broader engagement drawing on the domestic world of religion, and to a definitive civic engagement with rights and collectives.

Nevertheless, some physicians emphasized the worth encoded in the industrial world. While participating in the civic world of health rights, physicians may also attach worth to the professional world, with its arrangements of qualifications and capabilities to ensure quality (cf. Boltanski and Thévenot 2006). In an article describing the services delivered by the Trivandrum Institute of Palliative Sciences (TIPS) and Pallium India, Krishnan et al. (2018) wrote:

Given the vast need for palliative care in the community, a balance of quality care and coverage is challenging. Pallium India’s initiative, which resulted in the creation of a minimum standards tool in palliative care, is aimed at drawing a line below which the service should not drop. Nevertheless, the line seems too low, and services are often inadequate. A weekly home visit is hardly sufficient to ensure reasonable quality of care for a patient with advanced cancer.

Here, the physicians are reflective of the organizations—TIPS and Pallium India—and they indicate how they were pushing for higher professional standards. A senior palliative care physician shared with us the need for professional standards to preempt harm:

Palliative care service must maintain some minimum standards, which should be respected. There should be at least a certain number of hours of training. Plus, if you do not follow up with mentored practical training, the effect could be adverse. This is not only for volunteers but also for doctors and nurses. It is easy to do harm. As the expertise drops, the potential to do harm increases. Minimum quality standards are very important because if we don’t follow them, we have the potential to do more harm.

Highlighting the role of calculations from the industrial world, the physician clarified that the potential to harm could arise because of deviations from proper training and professional conduct. Emphasizing these calculations of worth from the industrial world, he stressed that palliative care requires attention to more technical expertise, professionalization, and training (cf. Boltanski and Thévenot 2006).

In sum, in the industrial world, worth is assigned to those with technical expertise because they are considered optimal for providing palliative care. As Boltanski and Thévenot (2006) note, in this world, “the scale of qualification underlies a hierarchy of status of worth, a hierarchy marked by competencies and responsibilities” (p. 206).

The inspired world

The inspired world exercises worth with attributes that cannot be measured by the market or industrial forms. These attributes manifest as independent actions, passions, and rejections of dominant norms (Boltanski and Thévenot 2006). Although these situations are not common in our setting, they are exemplified by caregivers who refuse to follow the dominant norms of making money or pursuing stable jobs to chart their course. An illustrative situation was Suresh Kumar’s commitment to community care. He recollected:

In 1993, I had two jobs. I was an anesthetist and was also volunteering. By 1995, I moved full-time into [community palliative care]. I was the secretary for six years, then someone else came in. Now, I am a regular member; being a member does not mean I get any extra benefits. It just means I must put a bit more time into this.

“A bit more time” has meant nearly three decades of full-time work in community palliative care and a refusal to follow the conventional path of lucrative medical practice by a young anesthetist graduating from a leading medical school. Over multiple interviews, Suresh spoke at length about the organizational aspects of care but effaced personal biographical trajectories. Suresh was impelled by a moral imperative to serve vulnerable patients and inspired many to serve. For instance, Zainab shared:

Doctor Suresh is our role model. He is a very simple person. He enjoys being with us. Almost all the doctors here are very simple, loving, and happy. There is no hierarchy here, so these are elements that differentiate us from other places.

Despite Suresh’s pioneering role and international recognition as a palliative care physician, young volunteers like Zainab found him accessible and “simple,” a colloquial description of someone inspirational who has no desire for fame or material wealth. Thus, worth in the inspired world is calculated on the basis of the transcendence of dominant norms.

Highlighting a similar calculation of worth, Chitra Venkateswaran shared that her quest for a meaningful affiliation led her to a postgraduate medical specialization in psychiatry. Her subsequent foray into palliative care, however, was transformative:

There was always a restlessness to do something more. It was undefined at those stages. I was looking for something that could give meaning. Palliative care principles, or the broader philosophy, apply to every kind of care that you give. I think my life changed after this whole thing. The whole path, approach, me as a person, the way I care for people, the way I manage people, and my team…everything has changed.

The inspired world attributes worth to engagements that may be unusual, risky, and exciting (Boltanski and Thévenot 2006). Like Suresh, Chitra rejected the market and industrial worlds of money and traditional careers and switched to the less financially gainful and emergent palliative care field. Chitra now runs a nonprofit organization focused on mental health, which draws on palliative care volunteer networks. These are unusual career choices for Indian middle-class professionals and illustrate the inspired world’s conventions.

The domestic world

The domestic world refers to worth ascribed not just to family relationships, but to relationships of personal dependence (e.g., superiors or visitors) shaped by tradition, hierarchy, and habits (Boltanski and Thévenot 2006). Specifically, in some settings, caregivers highlighted the domestic world’s significance by pointing to religious traditions. Consider Abdul, a founding member of a community organization in Malappuram:

Our religion tells us to help others. If we have earned well, then people who are struggling automatically have a share in our earnings. We have been instructed by God to help others, and surely, we will be rewarded for our actions.

Abdul’s location was shaped by religious affiliation. His service made him worthy within the bounds of a higher principle: his religious duty. Like Abdul, Muslim volunteers referred to the Islamic moral tenet of Zakat or donating 2.5% of one’s total income to charity. In the domestic world, traditions of duties and hierarchies of commands are paramount. Therefore, Abdul followed religious tenets to help others.

While Islamic practices are salient, particularly in North Kerala, Jayakumar, a volunteer at Aluva (Central Kerala), justified his involvement in terms of the Hindu principles of karma:

We don’t expect benefits. Maybe we can hope our family will get benefits. Karmanye vadhikaraste ma phaleshu kadachna, Ma karma-phalahetur bhur ma te sangostvakarmani [You have a right to perform your prescribed duty. You are not entitled to the fruits of action. Never consider yourself the cause of your activities’ results, and never be attached to inaction or not doing your duty]. We cannot do our work expecting results. If our work is sincere, we will get some results. But we do not expect results. All we say is that whatever we get is enough.

Here, Jayakumar justifies his service through a Sanskrit verse from a Hindu religious text, the Bhagavad Gita, that lays down the moral need to perform one’s religious duty without attachment to the fruits of action. Although such a framing is distinct from the earlier Islamic articulation, both have a shared calculation of equivalence: one serves the vulnerable with the expectation of accruing rewards in another life. Thus, caregivers draw on worth embedded in the domestic world by following what they interpret from different situations as their duties, which are inscribed in religious traditions.

The market world

In the market world, self-interest, self-promotion, and outperforming competitors are of paramount importance (Boltanski and Thévenot 2006). We found situations in which caregivers offered services temporarily to further market goals. For example, Ram, a 25-year-old, shared how his leadership and communication skills improved after joining community palliative care as a volunteer during his undergraduate degree:

I came to palliative care and did a leadership program. I am usually given the responsibility to deliver presentations. We attended a conference. There were people from different countries. I had the responsibility to coordinate things. When [LS] Sir came here for an event, out of 15 people who had gone there, he recognized me. This was because of the work that I did. That is how we build relationships. When we went to [the conference], our presentation won certificates. I have a platform here, which is leadership. I have a chance here.

The market world’s worth does not mean that caregivers do not offer care. Rather, in this case, Ram seized the opportunities for self-promotion that arose through volunteering. He acquired leadership skills by mobilizing college youth and delivering presentations. In these types of market world calculations, building relationships can be beneficial (cf. Boltanski and Thévenot 2006). Ram made the most of the opportunities to interact with higher societal functionaries to further social networks, which further motivated his career aspirations for a high-paying, high-status government job. He was explicit about volunteering in palliative care as a stepping stone to successfully compete in the job market.

Consistent with S-D logic’s view of calculations impelling actors (Vargo and Lusch 2016), the market justification illustrates how individuals engage in resource integration and value cocreation, not only for others but also to calculate benefits for themselves.

The world of fame

In this world, recognition and public opinion establish the caregiver’s worth (Boltanski and Thévenot 2006). Some situations highlighted the world of fame in the community model. For instance, Jayesh, a volunteer, shared the following:

I got involved with palliative care in a big way. When we would get in a vehicle and drive to my neighborhood, people began to recognize. “I saw you earlier, driving that vehicle. What was that about? Oh okay, this is a very good initiative. It is a very good thing that you are doing. You must do this for people. It is important.” As a result, I got more deeply involved in this. Now, I’m involved in such a way that I cannot leave.

Jayesh described how people in his neighborhood appreciated his voluntary service. In this situation, Jayesh derived worth from others’ opinions. He added, “When we are walking on a road, [the patient’s] family members, relatives, and their children have great regard for us.” Such situations become defining for some caregivers, as the world of fame shapes their participation. As Boltanski and Thévenot (2006) note, “in the world of public opinion, the relation of worth is a relation of identification” (p. 181). Similarly, young volunteers to post Facebook and Instagram activity updates about their community service. Their participation in palliative care constructs a positive image of caring individuals in peer groups. For these volunteers, palliative care is a spectacle that provides visibility and recognition.

We also found that individuals interested in joining electoral politics realized that community care garnered them grassroots-level legitimacy and recognition, which could help them to further political careers. Participants gave the example of Saji Cherian, an elected representative of the state legislature from Chengannur city, who had worked as a volunteer and headed a community organization. He gained recognition in electoral politics and earned popular votes based on his palliative care work. Satya told us:

That is not an area [Chengannur] where CPM (Communist Party-Marxist) has influence. Saji Cherian won beyond the expectations of CPM. He was a popular palliative care volunteer in that district. His success is very good. CPM expected he would win by 5,000 votes. He won by 10,000 votes.

While caregivers like Saji Cherian may offer dedicated services without which they cannot gain popularity, their services may be calculatedly shaped by orders of fame and recognition.

In summary, the civic world defines the core of palliative care. The industrial, market, inspired, domestic, and fame worlds also shape transformative service situations. It is therefore erroneous to attach an individual to a single world. We witnessed a variety of situations because a diverse set of actors came together to offer palliative care. The diversity manifests in multiple orders of worth, which may also lead to conflicts between different worlds.

The Core-Ancillary Conflicts as Unintended Consequences of Multiple Conventions

Although there is a wide range of conflicts between different worlds, we focus on the key conflicts between the civic and ancillary worlds. These conflicts are unintended consequences that arise when caregivers weave together multiple conventions from diverse worlds in a transformative service system. Conflicts arise because worth is put to the test by conventions of different worlds (Boltanski and Thévenot 2006).

Challenging the core from the ancillary

A key dispute in the palliative field is over volunteers participating in the professional domain of palliative care and the potential dilution of professional care. Although the volunteers had been involved in palliative care since 1993, there were still situations where some physicians resented their role. In this clash, the industrial world’s attributes of specializations and expertise are considered worthy and are applied to test the civic world’s worth (Boltanski and Thévenot 2006). Hema is a physician who founded a nonprofit organization and engaged volunteers for palliative care. Consider the following situation Hema raised about monitoring the quality of volunteers’ care:

I have been with palliative care for the last few years. We are getting more volunteers, and I know training is important. We train, but we find it difficult. The more volunteers we have and the more we expand…how do you monitor and evaluate them? We are sending people. This is my organization, and I am sending you into the community. They are going as volunteers, but are they doing the right thing? How do we monitor and ensure what our volunteers are doing? Some might be giving them [patients] some information. Some might be treating them. I don’t know!

Hema transported a test of worth from the industrial world of professional capabilities and standards to the evaluation of volunteer participation, which draws predominantly on the civic world. Similarly, Sharmila, a paid staff at a community organization, noted:

It is a very delicate balance with volunteers because you are not paying them, so they are not accountable to you. There is a sense that I am doing you a favor by volunteering my precious time. Therefore, I am above your rules and regulations. That is not okay because you are coming here to help. The kind of leadership that needs to be demonstrated to volunteers is to say that “we are asking you to undergo a certain amount of training. We are not saying you are not good enough. You want to do a good job. You don’t want to do damage where you intended to do good.” I think it should be mandatory that they go through at least two to three levels of training, and that they are assessed, examined, and then allowed.

In this case, worth was attributed to those who were well-trained. Sharmila drew on the industrial world’s conventions to cast community palliative care as a technical issue rather than as a social or civic issue. These tests of the civic world were based on the principles of professional competency and technical standards from the industrial world.

Challenging the ancillary from the core

In this type of conflict, disputes arise when the civic world denounces the ancillaries as they manifest in the community model. The conflicts between the core and the market or fame world became particularly salient in more recent years with the increased number of caregivers. Newer entrants may have been offering services for shorter periods and may thus have been impelled by market or reputational gains. Senior caregivers resented such emphases and used conventions from the civic world to challenge these actions. Philip, a volunteer involved since 2003, critiqued quests for worth in the fame and market worlds:

Some want to take credit. We avoid taking photos and all. Earlier, if we gave 100 rupees for charity, no one would come to know about it. Now, if people give 10 rupees for charity, they want to take a photo if I am giving 1000, what benefits am I getting? There are some basic things we learned during training. People are getting diverted from that. For the doctors who are here today, it is an earning thing for them. The medicines that they give are prescribed according to the pharma companies. They [doctors] can do it differently without using costly medicines. Earlier, we discussed all the patients’ cases with the doctor. Now, they have no time.

Referring to caregivers’ use of social media such as Facebook to publicize their actions, Philip criticized the pursuit of attention, the visibility acquired from photographs, and the publicity around charitable acts attached to the world of fame. Philip noted, “The involvement of youth is much less” and was unhappy with youth engagement in palliative care as a spectacle. For him, such volunteering was also a form of frivolous self-promotion located in the world of fame, through which volunteers met patients, took selfies, and then considered their role to be over. Taking a swipe at the industrial and market worlds, he used the civic conventions of collective welfare to denounce physicians who profiteered by prescribing medicines based on pharmaceutical firms’ recommendations. Philip stated, “If our mind is committed to service, we cannot make a profit out of that.” Similarly, Bindu, a palliative care nurse at a district hospital, shared the following:

One should have interest. Palliative care is not just a job because it is not a very pleasant thing. When we go for homecare, we may have to climb on top of a mountain to see one patient. If I am cursing the mountain and the patient, what palliative care am I going to offer? So, anybody coming for palliative care should not approach it as a salaried position or a job. The attitude of the person is very, very important.

Bindu described palliative home care as challenging work, which may involve traveling across difficult terrains. For her, the market world of money and the industrial world of careers had limited worth. She emphasized that caregivers needed to have an appropriate attitude or commitment to collective welfare in the civic world.

In sum, we witnessed several conflicts between the core and the ancillary worlds. Thus, it has been shown that while a test from the industrial world primarily marks the most salient challenges to the core, denunciations from the civic world challenge the ancillaries.

The Reconciliation of Conflicts in Transformative Service

Conflicts arise as unintended consequences of a transformative service with arrangements in different worlds. We identify three key ways in which conflicts are reconciled: compromise between core world and ancillaries, resolution in one world, and discontinuation of participation (see Figure 1).

The compromise between the core and ancillary worlds

Caregivers may resolve core-ancillary conflicts through compromises. A compromise is a situation in which conventions from opposing worlds are allowed to coexist (Boltanski and Thévenot 2006). Medical professionals, who emphasize professional care, and caregivers, who foreground social care, create compromises by drawing on the conventions of opposing worlds (i.e., the industrial and civic worlds). Some medical experts acknowledge these compromises. For example, despite medical expertise, Rajagopal acknowledged the following in a media article (Malayala Manorama 1995): “volunteers are the backbone of this establishment. Volunteers work hard without expectations of monetary gains. Volunteers carry the primary responsibility at this clinic.” Similarly, Mohammad, a physician employed by a community organization, reflected on the compromise between the industrial and civic worlds:

When we see some volunteers’ notes, they know how to manage the patient better than the doctors. They know the patient very well. Community volunteers are people living in the neighborhood. I live far away. They [volunteers] know the patients very well; they know their relatives, and they know who cares for them. Doctors and nurses don’t have those insights. Volunteers are a must.

Although Mohammad realized the significance of medical experts, he also outlined the necessity of volunteers with specific understandings of neighborhoods and patients. Hence, the community model requires a compromise between the industrial world of technical knowledge and efficiency and an emphasis on social care marked by the civic world.

A compromise between different worlds became salient in collaborations between the community organizations and state-run PHCs. While the latter were expected to collaborate with community organizations, state procedures dictated their everyday functioning. Numpeli described how early community organizations conscripted the PHCs into providing care. While some PHCs expressed interest in supplying medicines and catheters, their nurses were overburdened and unavailable. Numpeli explained a compromise creatively engineered between community organizations and PHCs:

In Nilambur and Areakode, the community organizations told PHCs, “We will provide the nurses.” They sent nurses from [community] palliative care to a PHC. This is not a small thing. It could manifest as “we are good people, and you are useless”—that kind of approach. We did not take that approach. We told them, “You can do it. We will help you.” We sent nurses from here, and it was a success.

Therefore, a conflict situation between the two worlds was resolved through a compromise in which community organizations operating in the civic world contributed to supporting PHCs operating in the industrial world of medical expertise and standards. These community initiatives laid the groundwork for the 2008 policy in which the state committed to offering palliative care in its health facilities. While reinforcing the civic world’s dominance, such a public policy formulation stabilized a compromise with the industrial world.

The resolution in one world

We found that individuals reconcile disputes by using one world’s conventions to justify a moment of truth while holding other worlds as less worthy. Unlike reconciliation as a compromise in which contradictions between core and ancillaries coexist, resolution in one world is achieved by rejecting the ancillaries’ conventions and allowing the civic world’s conventions to dominate. Here, individuals reject all ambiguities that might allow “alternative truths” to emerge (Boltanski and Thévenot 2006, p. 138).

During a field visit to one of the early community organizations, we met Amjad, a volunteer from a working-class family who had dedicated nearly 20 years to community palliative care. He expressed deep anger over a few pioneering physicians receiving media accolades, government and civil society awards, and international recognition since the community model had developed through the grassroots with the support of community actors typically from working-class or lower middle-class backgrounds. With indignation, Amjad remarked, “Palliative care is of the community. How can one individual get an award?” Here, the volunteer equates palliative care with the civic world and rejects the world of fame. The primary order of worth here is the community’s collective participation.

In these situations, dispute settlement between the civic and ancillary worlds occurs by rejecting the latter’s worth. In a similar vein, some senior caregivers denounced a flash mob organized by student volunteers as a palliative care awareness campaign, and they stopped the volunteers from organizing such activities. A volunteer explained, “They [the senior caregivers] say that ‘a flash mob is not palliative care. It is not suitable for us.’ There is such a kind of control here.” Senior members deploying the civic world of participation condemned the youth flash mob initiative as a spectacle for fame. Here, “control” implies that volunteers resolved this conflict in the civic world and rejected the ancillaries’ conventions.

Similarly, some participants opposed the founding of community organizations that identified with a specific religion or party ideology. Philip stated, “There is a new trend now: Christians have a palliative care organization, and Muslims have different ones. Our [community palliative care organization] is a common ground.” He was emphatic that palliative care must be defined by the civic conventions of solidarity and collective welfare rather than the hierarchies and traditional conventions of religion in the domestic world. Thus, while various motivations—including religious or political ideologies or professional commitments—may inform individuals’ actions, participants pointed out that an organization cannot espouse a single religion or ideology.

There is a similar rejection of the market world of money. For instance, Misa, a homemaker who volunteered, shared how even if she could make money during the time she volunteered, this would be incomparable to her service:

In this time, I can make 100 rupees more, but what will I do with that money? I can do something for my children. What else can I do? I should do something useful for society. I need only this much money. There are no other needs for me.

A common refrain among volunteers was the rejection of money as a signifier of market worth and as antithetical to the civic world’s principles. In these cases, individuals settled disputes between worlds by rejecting the market world.

The discontinuation of participation

In some situations, neither an acceptable compromise nor a resolution in one world is feasible. Consequently, caregivers may discontinue participation. It was found to be common to see caregivers discontinuing after training or a few months of service. Such caregivers typically failed to come to terms with the civic conventions and found it difficult to sustain services. Mathew, a volunteer trainer, shared how publicity as a marker of the world of fame had limited potency in such care settings:

If I am coming for publicity, I cannot stay here because here there is a lot of pain, a lot of compassion, and a lot of care. After a few days, I realize that there is no space because most of them suffer in pain. If I am only looking for fame, there is no space for that. We reach that place automatically [and quit].

Mathew explained that volunteering could be physically and mentally demanding labor. Mathew recounted one of his first home care visits, where he bathed a burn victim. A tall, healthy person in his 40s, Mathew recollected stepping outside the patient's house and collapsing to the ground from the sheer mental and physical exhaustion. Like Mathew, other volunteers informed us of volunteer attrition once they realized that there was limited scope for furthering self-interest, careers, or self-promotion. His is not to say that most palliative care volunteers are not in it for self-aggrandizement. Nor do we suggest that logics built on the calculative idea of calculative market exchange, such as the S-D logic, are unable to contribute to well-being. Rather, there is a limited scope of such conventions of the domestic, industrial, market, inspired, and fame worlds in sustaining commitment and solidarity.

We also found instances where participants discontinued participation when the ancillary worlds crowded out the civic world’s worth. For instance, Shafiq shared an example of a failed community organization in Palakkad district:

In my region, there was a palliative care organization that began three times and failed. Through this, I learned one lesson. It did not fail because of a shortage of funds. The people founding the organization had problems attracting and retaining people. They were the hindrance to others joining the organization. Like gatekeepers. Later on, I realized it’s all about teamwork. There should be no concept of a leader, or one person who uses the charitable organization for personal benefits that are different from the organization’s aims and purpose.

Shafiq explained that at this community organization that failed to retain volunteers, the founding members were invested in personal gains, self-promotion, and individual recognition. Such orders of worth located in the market and fame worlds displaced the civic notions of teamwork, led to caregivers exiting the initiative, and eventually contributed to the failure of the organization.

In summary, we have surfaced the unintended consequence of conflicts between different worlds stemming from the multiple orders of worth. We have also explored three approaches by which individuals reconcile these conflicts. Our findings show that at the core of palliative care is a partial rejection of the regime of justice to offer care. We discuss the regime of agape as an important feature of transformative service in the next section.

The Regime of Agape in the Community Model

In the earlier sections, we have shown how the community model provides transformative service at the interstices of multiple worlds of justice with accompanying conflicts. We also found the regime of agape to be an unintended but highly desirable component of the transformative service system, as illustrated in Figure 1. Here, we detail those moments in which actors discard strategic and calculated actions and operate in a regime of agape where they offer love and unbounded care. Agape is an unintended consequence because caregivers do not strategically design agape to further palliative care. Rather, agape is an emergent feature of the community model when caregivers commit to offering transformative service.

Love and unbounded care

Most caregivers join the community model as part of civic participation. As they immerse themselves in alleviating vulnerable patients’ suffering, they experience agape or giving gratuitously as part of love in certain situations. Agape makes no demands, and one of the pathways to agape is to anticipate what is not requested (Boltanski 2012). Consider Zainab, who had volunteered for 6 years since the start of her undergraduate program. Zainab’s first patient left an indelible impression on her:

My first cancer patient that I took care of influenced me tremendously. I met [patient’s name] only three times. Even after we knew he would not be there with me for long, it was a loving relationship. I know his parents, who are also palliative care volunteers, and they are great people. Whatever I have done afterward is for [the patient’s] mother. She is very close to me. I cannot express the emotions I have for her. It is unconditional love toward her.

While volunteer tasks typically involve bereavement support for the family only in the months after a patient’s demise, Zainab had maintained a long-standing relationship with her first patient’s mother. In a site of grief and loss where there is no scope of reciprocity or justice, Zainab described her bonds of affection and love for the bereaved mother. Similarly, Manju, a nurse at a PHC, said, “If patients are bedridden, we do what we can. We collect information. We make them understand. We provide love and help. Then comes the treatment.” Indeed, caregivers referred to sneham (love) frequently in reference to palliative care. In 1995, Malayala Manorama, the leading vernacular daily newspaper, published an article titled, “Vedana oppaan snehasandhvanam” (loosely translated as “offering loving comfort to absorb pain”) on the first palliative care clinic at Kozhikode. The article documented the plight of patients in excruciating and incurable pain before the clinic’s founding. It highlighted the caregivers’ selfless work at the clinic and the families’ affection toward them. Lisy, one of the three earliest volunteers, was cited as saying, “My reward is that patients who walk in here in pain go out of the clinic with a smile on their face.” While some caregivers explicitly invoke love in their care provision, Boltanski (2012) points out that agape may not be articulated categorically; instead, it may be implicit in action. We found that caregivers transcended their roles and offered care in every possible sphere of influence that encompassed multiple dimensions of patients’ needs. Abdul explained:

We not only give medical help, but we also provide food, medicines, and educational help for the patients’ children. It is basically total care. Irrespective of caste, creed, and religion, every person benefits.

In such cases, agape does not depend on the recipient’s value and has no preferences (Boltanski 2012). Elias, who had just completed his undergraduate degree, commuted from his town to volunteer at a community organization in the neighboring city where he spent 7–8 hours every day. His mother was also a palliative care volunteer. Elias shared:

When they go home, patients will not have money to pay rent. They don’t have anyone to help them. We will do something for them, like give them a small mobile phone or food items. We arrange small funds for their small requirements. We are not expecting anything back.

Caregivers like Elias anticipate patients’ needs when they leave the hospital and return home. They assist the patient with whatever problem they can address to reduce strife and pain and create harmony. During field visits, we frequently encountered stories of volunteers fulfilling dying patients’ desires for eating biryani or samosas by preparing the dishes themselves or uniting estranged families during patients’ last days. Anticipating and fulfilling these multiple dimensions of patients’ needs is demanding. Zafrina, a long-term volunteer and then a trained nurse and core member at a community organization, described how volunteers contributed:

This activity doesn’t have a definite time for work. Volunteers first go and check the patient’s condition at their houses and inform us so that we can see if a doctor and nurse are needed. Volunteers are always busy. There is no day and night for them. If someone is unwell, it is a must for the volunteers to check on the patient. Also, the [volunteer] meetings happen in the mornings, evenings, and any time.

Similarly, Ayesha, a nurse in her 20s who worked at the Kozhikode Medical College and volunteered during her spare time, noted:

Once my shift is over at 1:30 p.m., I will be here by 2 p.m. [at the community center], and I stay until 8 p.m. If I have a night shift, I just go and freshen up, and by 12 p.m., I come here.

Nurses at public hospitals have a high workload. Ayesha dedicated her leisure time to volunteering after intense nursing work at a public hospital. One of the pioneering volunteers, Geeta, poignantly explained the unbounded nature of such care in the regime of agape:

There are limitations to treatment. Through palliative care, we must understand that there are no limitations of care. Can we say that we can give only so much care? No, we can’t say that because we can always give care. But there are limitations to treatment.

Treatment can be provided only when the patient responds to it; in contrast, transformative care for Geeta was limitless. In agape, an individual can anticipate others’ needs by referring to her own needs and giving more (Boltanski 2012). Striving for a state of love, the caregivers we interviewed breached boundaries that limited care as a technical outcome.

Suspension of calculations

In the regime of agape, care as a gift to the recipient is not envisaged with the expectation of a countergift; acts in a regime of agape occur without any particular calculation. As Boltanski indicates (2012), “All persons in agape impoverish themselves in response to the impoverishment they encounter” (p. 147). Indeed, Geeta started volunteering when she and her husband had a 3-year-old daughter and a mortgage. She recollects a patient telling her, “Why do you come here for free work? If you are at home, at least you can pull out the weeds in your front yard.” Despite such reminders of losses, Geeta volunteered full time for years, forfeiting private gains even when her family faced financial hardships, and her husband was the sole breadwinner.

Several elements of giving without calculations in agape are corporeal. For instance, we met a young volunteer in her 20s who donated a kidney to her patient. While such instances are rare, corporeal commitments in the regime of agape are routine. Consider, Satya who had conducted a 2.5-hour training session for volunteers the day we interviewed him despite recovering from a knee fracture; he had started walking only a few weeks before our interview. He explained as follows:

In 2.5 hours, when I was teaching the class, I did not know about that pain. This is possible only with that level of dedication. After some time, people think of family, jobs, and other things. These are individualistic things. I am not saying to keep those things aside. But one has to be ready for a “denial.” They have to sacrifice (tejjikyuan tayar avanam) something in life. Without this, people cannot work in palliative care.

Satya referred to sacrifice as the suspension of calculations and giving without thinking about personal costs, and this is a key feature of the community model. Such sacrifices may include undergoing physical pain and material renunciations. These sacrifices, the denial of equivalence, and giving without reciprocal expectations make agape a special love distinct from eros (Boltanski 2012). As Belk and Coon (1993) articulate, “agape is sacrificial where eros is acquisitive; agape is unselfish where eros is egocentric; and agape gives freely where eros is possessive” (p. 407).

Radha, a volunteer from an agrarian family, reminded us of “the insouciance of agape” in giving without any calculation of gain (Boltanski 2012, p. 114):

We don’t even take a glass of water from them [patients] when we are there for service. I am not working for money. Everything is going on smoothly. I am not expecting anything from them.

Patients are typically bedridden or terminally ill, while families are often destitute, and caregivers like Radha do not seek benefits from their gifts of service. In these ways, we found that caregivers articulated agape as unbounded care, love, and the suspension of calculations.

In summary, agape is central to transformative service. We are not suggesting that caregivers always operate in a state of agape, nor are we maintaining that transformative service is not possible without agape. Indeed, prior S-D-logic-informed TSR has shown that interventions and organizations relying on justice can create transformative service (e.g., Anderson et al. 2016; Baron et al. 2018). Rather, we posit that agape is an important facet of the care provided that, when overlooked, renders service provision as a calculative practice enmeshed in a world of equivalence. In the following section, we elaborate on how patients experience the community model as a transformative service.

The Community Model as a Transformative Service

For socially disadvantaged and vulnerable patients, the community model delivered transformative service. Consider Achapan, a 70-year-old from the Adivasi (indigenous or scheduled tribes) community, which was among Wayanad’s poorest. Achapan and his wife lived with their daughter, who had a speech disability, and her son. This family lived atop a hill in a two-room house built through a state welfare housing policy for the Adivasis. When we visited Achapan, he was grieving for his son, who had died 2 weeks prior from an undiagnosed condition. Around 2009, Achapan had suffered a paralytic stroke while doing manual labor and was bedridden for a few years. He had partially recovered and would walk 12 km through Wayanad’s hilly terrain to the nearest PHC for consultations and medicines. Achapan shared the following:

I had to climb to go to the hospital. I had to spend money. I cannot walk by myself from here anymore. I cannot travel or walk alone. Now, they [community caregivers] will come here. They give me English medicines [allopathic medicines]. Earlier, I used to buy them. These were very expensive at 200 rupees [monthly expense]. I get 1000 rupees in a month as wages.

In India, approximately 80% of individuals’ health care expenditures are driven by out-of-pocket expenses. Hospitalization becomes a catastrophic expenditure resulting in “health care impoverishment,” which refers to a decline in socioeconomic status because of health expenses (Garg and Karan 2009). In the context of overburdened public hospitals and the absence of social security programs, having caregivers visit their homes with free medicines and food kits is transformative for low-income patients. In this site of destitution and health-related suffering, the local community organization’s services over the last 3 years provided Achapan with considerable relief. With a wide toothless smile, Achapan pointed to the student volunteer accompanying the nurse and added, “He brings me things from the bakery.”

While low-income families valued free medicines and regular nursing care, middle-class families valued direct access to professionals and the volunteers’ social support. Consider the experience of Shazia and Naz, a middle-class couple residing in Kozhikode city, whose 3-year-old daughter died of cancer after treatment and two relapses. Their child received palliative care in the last 3 months of her life. In contrast to their long, nightmarish waiting hours at the government hospital for cancer treatment, they were relieved by the round-the-clock access to senior palliative care physicians at their homes. Shazia shared, “It [community palliative care] is given by veterans! These doctors, especially I should say [a senior physician], would pick up the call anytime.” Shazia recalled the volunteers’ care:

I was amazed. We actually got to see the volunteers’ strengths. How much they were doing! Even the driver, he comes home. He left this job, and since then, he has still stayed connected. He spreads the word. He talks about this service. He goes to people to tell them more about how it works.

Shazia described their relationship with the home care vehicle’s driver. Even after moving to another full-time job, he stayed connected with her family, reflecting a commitment exceeding calculated exchange. Further, the driver spread awareness about palliative care, performing a function distinct from that of medical professionals. Naz revealed the following:

They take care of everything there [referring to the community model]. They connect with you so much. They also supported us emotionally, and even after the death, they were with us, and they continue with it. When we go there and come back, we feel happiness.

Naz described the emotional connection and the happiness experienced paradoxically at a site of pain and dying. Importantly, Shazia and Naz now volunteer for palliative care, and such commitments are indicative of porous, collaborative patient-provider relationships.

This community model also transformed the lives of patients confronting social isolation. For instance, Kannan was bedridden after an accident and confined to one room in his parent’s house for 26 years. Kannan’s release from isolation, abandonment, and neglect came when a home care team visited his house for a neighborhood survey:

There should be a person in the house who understands. Otherwise, one’s life is hell. We lay in a corner and rotted. We were like birds without feathers—alive but afraid. For people like us who have spinal injuries, this [community organization] is like a big family and is a sandhvanam [palliation], or a blessing. Nine out of 10 of us need emotional support. If we get a person who understands this and just listens to us, that for us is the blood that runs through our body. Now I am like a bird with new wings. I can fly.

Thus, community palliative care extends beyond the biological limits of medical treatment and the common world of family. Kannan elaborated:

We have had so much change because of this organization and its camps. Day or night, they do not abandon us. They have good hearts. These people have shown us that they are also like us. They don’t have the notion of being a doctor, nurse, or volunteer. They behave like one of us, sit, and have food with us. It’s not a profit-making venture—it’s not seeking a reputation. We want it to grow; that is our prayer. What one gets from a family, one gets much more here. For a patient who lies in his house without seeing the light of the day, what he gets out of this is a new life.

From his experience of receiving care, Kannan did not consider the organization as engaged in calculative practices for reputation or profits. Rather, the caregivers became part of the patients’ lives and set their distinctions aside to offer a transformative service and “a new life.” In these ways, the patients experienced transformative care through the community model.

In summary, the community palliative care model is a transformative service system that has significantly improved health care access, particularly for the marginalized in Kerala. This transformative service attracts caregivers from different walks of life and creates situations involving conventions from different worlds with conflicting orders of worth. Regimes of justice and agape constituted transformative service in Kerala. The two regimes of justice and agape have been shown to be porous, and we found that caregivers can cohabit these positions or move from one to another, depending on their situations, to offer care.

Discussion and Conclusions

In this article, we show that community palliative care is a transformative service that has generated uplifting change and well-being for millions of patients with chronic and terminal conditions in Kerala, India. In a setting where the state-run interventions are overburdened and private enterprises have failed to cater to the poor, community caregivers have offered transformative service to the most vulnerable. Our attention to multiple conventions and the regimes of justice and agape foregrounds the undesirable and desirable unintended consequences of a transformative service system (see Figure 1) and helps to conceptualize a dialectical framework. Accordingly, we make several contributions to TSR.

Incorporating S-D logic, Vargo and Lusch (2016) define a service (eco)system as a “relatively self-contained, self-adjusting system of resource-integrating actors connected by shared institutional arrangements and mutual value creation through service exchange” (pp. 10-11). S-D logic has played an important role in shaping TSR (Baron et al. 2018) and specifically studies on health care (e.g., Anderson et al. 2016; McColl-Kennedy et al. 2012; Sweeney, Danaher, and McColl-Kennedy 2015). This research stream has shown that emphases on the cocreation of value and resource integration can foster individual and collective well-being (Anderson 2010). While these studies offer vital insights, they monochromatically limit TSR to the exchange paradigm (Belk and Coon 1993).

In contrast, we argue that transformative service is constituted by a complex palette of relationships. Our study suggests that S-D logic and its concepts, such as resource integration and value cocreation, inadequately explain transformative service because of the focus on calculative market exchanges. Based on our findings, our framework contributes to TSR by conceptualizing a transformative service system as a dialectical synthesis of the regimes of justice and agape. Such a system offers care that generates uplifting change, promotes well-being, and alleviates suffering. In our framework of a transformative service system, actors construct transformative service around the civic world’s core conventions that value solidarity, collective welfare, civic responsibility, and participation. This core world is interwoven with ancillaries—the industrial, market, domestic, inspired, and fame worlds—for service provision. Our framework shows that transformative service involving community participation requires attention to different orders of worth. Indeed, there is a need to broaden our understanding of TSR to include disparate conventions within the regime of justice.

We found that the civic world, which emphasizes moral responsibility and solidarity, is central to transformative service. Our findings show that S-D logic, with its focus on individual gains and responsibilities through cocreation and resource integration, may crowd out the civic world’s imperatives and hamper transformative prospects in settings of stark material inequalities. While this is evident in our Global South context, the limitations of S-D logic can also be determinantal in the Global North. For instance, in their ethnography of a nonprofit delivering transformative value in the United States, Blocker and Barrios (2015) highlight varied processes of constructing communitas, facilitating spiritual flow, and demanding civic responsibility. These elements resonate with our findings of diverse ancillaries (e.g., inspired and domestic worlds) interwoven with a transformative service system’s civic core. Thus, our framework underscores the need for attention to a broader set of conventions.

We further show that such a palette with diverse conventions leads to the unintended consequence of disputes between different worlds. While the institutional perspective in S-D logic (Vargo and Lusch 2016) engages with contestation by focusing on interinstitutional conflicts, attending to conventions offers distinct advantages. For example, although institutional studies point to how services are exposed to competing demands from different institutional logics (Thornton et al. 2012), we know little about how conflicts between different worlds impact service provision at the microlevel of everyday actions (Cloutier and Langley 2013). We surface the multiple conventions governing everyday service situations, the conflicts arising thereof, and their reconciliation. Such a framework foregrounds the unintended consequences of interwoven worlds inherent to a transformative service. These consequences include the conflictual situations that arise when actors draw on the assumptions of ancillaries to challenge the core or when the civic core creates situations of disputes with the ancillaries. If unresolved, these conflictual situations can fragment the transformative service system.

We illustrate three types of conflict resolutions: compromise, resolution in one world, and discontinuation of participation. Conflicts as unintended consequences between linked worlds and conflict resolutions operate in the regime of justice characterized by calculations. We show how caregivers driven by the industrial world deem technical knowledge superior to the civic world’s social interventions. We also report disputes between the market and the civic world in routine actions and explain how individuals reconcile disputes between different worlds. Compromises can be fragile, and they highlight the challenge of multiple, conflicting worlds. Further, if a conflict is resolved by denouncing the civic world in favor of the market or fame wosrld, it may limit the service’s core transformative function. As our finding on the failed organization in Palakkad shows, caregivers may exit the service if the civic worth is crowded out. Thus, we contribute to TSR by explicating microlevel conflict reconciliation. In so doing, we add to the research suggesting that a harmonious view of transformative service does not resonate with empirical realities (Cabiddu, Moreno, and Sebastiano 2019; Echeverri and Skålén 2011; Skålén et al. 2015).

The above reconciliation of conflicts helps TSR move beyond the binary of legitimacy and illegitimacy central to institutional lenses of service systems. Such a binary fails to explain how a transformative service inheres a diverse set of service situations in which people from disparate backgrounds and motivations participate. We show that individuals may locate legitimacy in the framing of worth in a specific world. When different worlds come together, there can be situations of compromise between and cohabitation of diverse notions of worth beyond the binary of legitimacy and illegitimacy. Thus, we delineate a distributed spectrum of legitimacy with diffused boundaries.

Moreover, although some research attends to the role of morality in determining how different institutional logics prevail (cf. Baron et al. 2018; Blocker and Barrios 2015; Breidbach, Antons, and Salge 2016; Frow et al. 2016), these developments remain marginal to service research. Underexamining the moral dimensions of logics obscures a powerful motivator for why actors endorse or denounce one particular logic over another (Cloutier and Langley 2013). Our transformative service system framework foregrounds how caregivers’ morality furthers the civic world’s conventions over the industrial, market, domestic, inspired, or fame worlds. These moral notions trigger disputes between different worlds. Accordingly, individuals reconcile disputes within a specific moral order or devise a new moral framework of action around a compromise. Our study suggests that convention theory offers a vocabulary of morals that deepens our understanding of TSR.

Finally, our framework shows that agape is a highly desirable unintended consequence of transformative service. We found that caregivers suspended calculations based on reciprocal relations central to the exchange paradigm, and impelled by love, they operate in a regime of agape where they set aside the desire for equivalence. Agape’s fundamental tenets are antithetical to those of S-D logic. S-D logic stresses cocreation based on reciprocity (Vargo and Lusch 2016), which is a notion that has informed TSR. For instance, McColl-Kennedy et al. (2012) and Sweeney, Danaher, and McColl-Kennedy (2015) demonstrate how patients, as customers in a market, cocreate value by integrating resources for improved well-being. However, S-D logic and its “service ecosystem metaphor” comprise evaluation and exchange, which entail calculations. Our study shows that perspectives that privilege calculations neglect agapic action, through which caregivers silence their desires and offer unbounded care with no expectation of return or strategic benefit. Agape is based on selfless sacrifice (Belk and Coon 1993), and our findings support its role in this context, with one particular example showing that a young volunteer in her 20s donated a kidney to her patient. Such selfless behavior is also evident in how Geeta ignored her financial debt to volunteer full time for palliative care. Indeed, the lens of agape offers an alternative view of a health care context wherein caregivers improve patients’ well-being through situations of love and the suspension of calculations. Therefore, our framework, with its attention to the regime of agape, offers an important alternative to the dominant S-D logic lens and stands to expand conceptualizations of well-being in TSR.

Our study offers several implications for policy development and practice. The spread of COVID-19 during the writing of this article and the dramatic rise in serious health-related suffering, particularly in low- and middle-income countries, have cast in high relief the need for community health care models (Daniel et al. 2020). There is thus an urgent need to explore service delivery models beyond the prevailing hospital and hospice-based approaches that are limited in coverage and affordability. Kerala’s community model is one exemplary model that offers an alternative (Stjernsward 2005) in remodeling health services to empower communities. However, “community health intervention” is a popular buzzword in public health discourse and can be uncritically deployed, and such efforts obfuscate the plurality and tensions that underpin collaborations between medical professionals and community participants (Kumar 2020; Vijay, Whitelaw, and Clark 2020; Monin, and Kulkarni 2020). Further, these interventions can intentionally or unintentionally privilege the industrial world by evaluating service provisions based on professional standards and benchmarks, thereby crowding out the civic world or regime of agape. Our model shows the centrality of the civic world and agape in such an intervention that prioritizes civic/political rights, solidarity, and love, with several other worlds playing a supportive role. Moreover, designing compromises between different worlds can be central to the working of such transformative service systems. Finally, public health offerings cannot strategically design agape into interventions because this would introduce calculations. As Boltanski (2012) reminds us, agapic love cannot be forced, edified, or brought about intentionally. However, service systems that encourage caregiver interactions that shun or renounce calculated exchanges and reciprocity may gradually create spaces where caregivers can transition, even momentarily, to a regime of agape.

In conclusion, this article contributes by developing a framework highlighting how different regimes and conventions accomplish transformative service, how their relationships unfold, and how conflicts between them arise and are resolved. This article also contributes to TSR research by explaining the role of agape in transformative service. Our study surfaces several questions for future research. How do service providers in the regime of agape overcome the dominance of markets to restrict the influence of the exchange paradigm? How can agape further our understanding of “helping without harming”? How do noncommunity transformative service include different conventions and resolve conflicts? Studies may also attend to how conflicts arise from power struggles, a theme highlighted in the social sciences but not within service research. In settings of poverty and deprivation, the inclusion of actors from diverse backgrounds is critical for transformative services. However, such transformative service systems may have to transcend the narrow confines of markets and seamless resource integration to embrace a dialectic of justice and agape.

Footnotes

Acknowledgment

We are grateful to the special issue editors and the review team for their helpful feedback. We are indebted to the Kerala palliative care community for their generosity and support of this research. We would like to thank Aparna G., Wafa, Vishnu, and Prakash for their research and field assistance during various stages of this project. We are also grateful to David Clark and the End of Life Studies group at the University of Glasgow for collaborative work at various stages.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The first author received financial support for research from University of Birmingham. The second author received partial funding for the last phase (2019) of this research project from Scottish Funding Council under the Global Challenges Research Fund.

ORCID iD

Rohit Varman

Devi Vijay

Per Skålén

Notes

Author Biographies

Rohit Varman is a professor of marketing and consumption at the University of Birmingham. He uses interpretive methodologies, and his current interdisciplinary research focuses on violence, exploitation, and slavery. He has published his research in several outlets that include Journal of Consumer Research, Organization Science, Journal of Retailing, and Human Relations.

Devi Vijay is an associate professor at the Indian Institute of Management Calcutta. Her current research spans questions of inequality, institutions, and collective action, with a specific focus on health care. She has coedited Alternative Organizations in India: Undoing Boundaries (Cambridge University Press, 2018) and has published in journals including Journal of Business Ethics, Gender, Work & Organization, M@n@gement, Public Management Review, Marketing Theory, and Journal of Marketing Management.

Per Skålén is a professor of business administration based at the Service Research Center, Karlstad University, Sweden. He is currently working within the research streams of transformative service research, service innovation, value codestruction, and critical marketing and with applying practice theory, strategic action field theory, and other sociological theories to marketing research. His work has appeared in several journals including Journal of the Academy of Marketing Science, Journal of Service Research, Marketing Theory, Journal of Business Ethics, Journal of Public Policy & Marketing, Organization, and Tourism Management.

References

Al-Amoudi

Ismael

Latsis

John

(2014), “The Arbitrariness and Normativity of Social Conventions,” The British Journal of Sociology, 65 (2), 358–378.

Anderson

Laurel

Spanjol

Jelena

Jefferies

Josephine Go

Ostrom

Amy L.

Baker

Courtney Nations

Bone

Sterling A.

Downey

Hilary

Mende

Martin

Rapp

Justine M.

(2016), “Responsibility and Well-Being: Resource Integration under Responsibilization in Expert Services,” Journal of Public Policy & Marketing, 35 (2), 262–279.

Anderson

Laurel

Ostrom

Amy L.

(2015), “Transformative Service Research: Advancing our Knowledge about Service and Well-Being,” Journal of Service Research, 18 (3), 243–249.

Anderson

Laurel

Ostrom

Amy L.

Corus

Canan

Fisk

Raymond P.

Gallan

Andrew S.

Giraldo

Mario

Mende

Martin

Mulder

Mark

Rayburn

Steven W.

Rosenbaum

Mark S.

Shirahada

Kunio

Williams

Jerome D.

(2013), “Transformative Service Research: An Agenda for the Future,” Journal of Business Research, 66 (8), 1203–1210.

Anderson

Laurel

(2010), “Improving Well-Being through Transformative Services,” in Moving Forward and Making a Difference: Research Priorities for the Science of Service , Ostrom

A. L.

Bitner

M. J.

Brown

S. W.

Burkhard

K. A.

Goul

Smith-Daniels

Demirkan

Rabinovich

, Journal of Service Research, 13 (1), 4–36.

Anderson

Sidney

Nasr

Linda

Rayburn

Steven W.

(2018), “Transformative Service Research and Service Design: Synergistic Effects in Healthcare,” The Service Industries Journal, 38 (1-2), 99–113.

Arendt

Hannah

(1958), The Human Condition. Chicago, IL: The University of Chicago Press.

Barney

Jay B.

(1991), “Firm Resources and Sustained Competitive Advantage,” Journal of Management, 17 (1), 99–120.

Baron

Steve

Patterson

Anthony

Maull

Roger

Warnaby

Gary

(2018), “Feed People First: A Service Ecosystem Perspective on Innovative Food Waste Reduction,” Journal of Service Research, 21 (1), 135–150.

10.

Batifoulier

Philippe

Silva

Nicolas Da

Duchesne

Victor

(2019), “The Dynamics of Conventions: The Case of the French Social Security System,” Historical Social Research/Historische Sozialforschung, 44 (1), 258–284.

11.

Belk

Russell W.

Coon

Gregory S.

(1993), “Gift Giving as Agapic Love: An Alternative to the Exchange Paradigm based on Dating Experiences,” Journal of Consumer Research, 20 (3), 393–417.

12.

Blocker

Christopher P.

Barrios

Andrés

(2015), “The Transformative Value of a Service Experience,” Journal of Service Research, 18 (3), 265–283.

13.

Boltanski

Luc

(2012), Love and Justice as Competences. Cambridge, UK: Polity Press.

14.

Boltanski

Luc

Thévenot

Laurent

(2006), On Justification: Economies of Worth. Princeton, NJ: Princeton University Press.

15.

Boltanski

Luc

Thévenot

Laurent

(1999), “The Sociology of Critical Capacity,” European Journal of Social Theory, 2 (3), 359–377.

16.

Breidbach

Christoph F.

Antons

David

Salge

Torsten Oliver

(2016), “Seamless Service? On the Role and Impact of Service Orchestrators in Human-Centered Service Systems,” Journal of Service Research, 19 (4), 458–476.

17.

Bridson

Kerrie

Evans

Jody

Varman

Rohit

Volkov

Michael

McDonald

Sean

(2017), “Questioning Worth: Selling Out in the Music Industry,” European Journal of Marketing, 51 (9/10), 1650–1668.

18.

Cabiddu

Francesca

Moreno

Frau

Sebastiano

Lombardo

(2019), “Toxic Collaborations: Co-Destroying Value in the B2B Context,” Journal of Service Research, 22 (3), 241–255.

19.

Cappel

Valeska

Kappler

Karolin Eva

(2019), “Plurality of Values in mHealth: Conventions and Ethical Dilemmas,” in The Futures of eHealth: Social, Ethical and Legal Challenges, Bächle

T. C.

Wernick

Alina

, eds. Berlin, Germany: Alexander von Humboldt Institute for Internet and Society, 31–27.

20.

Cloutier

Charlotte

Langley

Ann

(2013), “The Logic of Institutional Logics: Insights from French Pragmatist Sociology,” Journal of Management Inquiry, 22 (4), 360–380.

21.

Danaher

Tracey S.

Gallan

Andrew S.

(2016), “Service Research in Health Care: Positively Impacting Lives,” Journal of Service Research, 19 (4), 433–437.

22.

Daniel

Sunitha

Venkateswaran

Chitra

Sunder

Poornima

Nair

Shoba

Chittazhathu

Rajashree K.

Manuel

Athul Joseph

Raghavan

Biju

Sunil Kumar

M. M.

Rijju

Vineetha

Vijay

Geetha

Rao

Seema

Prabhu

Anupama V.

Parameswaran

Uma

Spruijt

Odette

Rajagopal

M. R.

Leng

Mhoira

(2020), “Responding to Palliative Care Training Needs in the Coronavirus Disease 2019 Era: The Context and Process of Developing and Disseminating Training Resources and Guidance for Low- and Middle-Income Countries from Kerala, South India,” Indian Journal of Palliative Care, 26 (5), S8–S16.

23.

Davey

Janet

Grönroos

Christian

(2019), “Health Service Literacy: Complementary Actor Roles for Transformative Value Co-Creation,” Journal of Services Marketing, 33 (6), 687–701.

24.

Diaz-Bone

Rainer

(2016), “Convention Theory, Classification and Quantification,” Historical Social Research/Historische Sozialforschung, 41 (2), 48–71.

25.

Dubois

Anna

Gadde

Lars-Erik

(2002), “Systematic Combining: An Abductive Approach to Case Research,” Journal of Business Research, 55 (7), 553–560.

26.

Echeverri

Per

Skålén

Per

(2011), “Co-Creation and Co-Destruction: A Practice-Theory Based Study of Interactive Value Formation,” Marketing Theory, 11 (3), 351–373.

27.

Finch

John H.

Geiger

Susi

Harkness

Rachel Joy

(2017), “Marketing and Compromising for Sustainability: Competing Orders of Worth in the North Atlantic,” Marketing Theory, 17 (1), 71–93.

28.

Fougère

Martin

Skålén

Per

(2013), “Extension in the Subjectifying Power of Marketing Ideology in Organizations: A Foucauldian Analysis of Academic Marketing,” Journal of Macromarketing, 33 (1), 13–28.

29.

Frow

Pennie

McColl-Kennedy

Janet R.

Payne

Adrian

(2016), “Co-Creation Practices: Their Role in Shaping a Health Care Ecosystem,” Industrial Marketing Management, 56, 24–39.

30.

Garg

Charu C.

Karan

Anup K.

(2009), “Reducing Out-of-Pocket Expenditures to Reduce Poverty: A Disaggregated Analysis at Rural-Urban and State Level in India,” Health Policy and Planning, 24 (2), 116–128.

31.

Kierkegaard

Søren

(1995), Works of Love: Kierkegaard’s Writings, XVI. Hong

H. V.

Hong

E. H.

, Trans. Princeton, NJ: Princeton University Press.

32.

Krishnan

Anjali

Rajagopal

M. R.

Karim

Safiya

Sullivan

Richard

Booth

Christopher M.

(2018), “Palliative Care Program Development in a Low- to Middle-Income Country: Delivery of Care by a Nongovernmental Organization in India,” Journal of Global Oncology, 4, 1–8. doi: 10.1200/JGO.17.00168

33.

Kumar

Suresh

(2020), “Community Participation in Palliative Care: Reflections from the Ground,” Progress in Palliative Care. doi: 10.1080/09699260.2019.1706272

34.

Kumar

Suresh

(2013), “Models of Delivering Palliative and End-of-Life Care in India,” Current Opinion in Supportive and Palliative Care, 7 (2), 216–222.

35.

Laamanen

Mikko

Skålén

Per

(2015), “Collective–Conflictual Value Co-Creation: A Strategic Action Field Approach,” Marketing Theory, 15 (3), 381–400.

36.

Malayala Manorama (1995), “Offering Love to Absorb Pain,”Kozhikode Edition.

37.

McColl-Kennedy

Janet R.

Cheung

Lilliemay

Ferrier

Elizabeth

(2015), “Co-Creating Service Experience Practices,” Journal of Service Management, 26 (2), 249–275.

38.

McColl-Kennedy

Janet R.

Vargo

Stephen L.

Dagger

Tracey S.

Sweeney

Jilian C.

Kasteren

Yasmin van

(2012), “Health Care Customer Value Cocreation Practice Styles,” Journal of Service Research, 15 (4), 370–389.

39.

McCracken

Grant

(1988), The Long Interview. London, UK: Sage.

40.

Nygren

Anders

(1953), Agape and Eros. Watson

P.S.

, Trans. Philadelphia, PA: The Westminster Press.

41.

Palat

Gayatri

Venkateswaran

Chitra

(2012), “Progress in Palliative Care in India,” Progress in Palliative Care, 20 (4), 212–218.

42.

Patriotta

Gerardo

Gond

Jean-Pascal

Schultz

Friederike

(2011), “Maintaining Legitimacy: Controversies, Orders of Worth, and Public Justifications,” Journal of Management Studies, 48 (8), 1804–1836.

43.

Philip

Rekha Rachel

Venables

Emilie

Manima

Abdulla

Tripathy

Jaya Prasad

Philip

Sairu

(2019), “‘Small Small Interventions, Big Big Roles’—A Qualitative Study of Patient, Care-Giver and Health-Care Worker Experiences of a Palliative Care Programme in Kerala, India,” BMC Palliative Care, 18 (1), 16–25.

44.

Rajagopal

M. R.

(2015), “The Current Status of Palliative Care in India,” Cancer Control, 22, 57–62.

45.

Rajagopal

M. R.

Joranson

David E.

(2007), “India: Opioid Availability—An Update,” Journal of Pain and Symptom Management, 33 (5), 615–622.

46.

Reynolds

Lois A.

Tansey

E. M.

(2004), Innovation in Pain Management, Vol. 21. London, UK: The Wellcome Trust Centre for the History of Medicine at UCL.

47.

Sharma

Shikha

Conduit

Jodie

(2016), “Cocreation Culture in Health Care Organizations,” Journal of Service Research, 19 (4), 438–457.

48.

Skålén

Per

Aal

Kotaiba A.

Edvardsson

(2015), “Cocreating the Arab Spring: Understanding Transformation of Service Systems in Contention,” Journal of Service Research, 18 (3), 250–264.

49.

Spanjol

Jelena

Cui

Anna S.

Nakata

Cheryl

Sharp

Lisa K.

Crawford

Stephanie Y.

Xiao

Yazhen

Watson-Manheim

Mary Beth

(2015), “Co-Production of Prolonged, Complex, and Negative Services: An Examination of Medication Adherence in Chronically Ill Individuals,” Journal of Service Research, 18 (3), 284–302.

50.

Spradley

James P.

(1980), Participant Observation. Wadsworth, OH: Hampshire.

51.

Sreekumar

Hari

Varman

Rohit

(2019), “Vagabonds at the Margins: Acculturation, Subalterns, and Competing Worth,” Journal of Macromarketing, 39 (1), 37–52.

52.

Stjernsward

Jan

(2005), “Community Participation in Palliative Care,” Indian Journal of Palliative Care, 11 (2), 111–117.

53.

Summers-Effler

. (2007), “The Emotional Significance of Solidarity for Social Movement Communities: Sustaining Catholic Worker Community and Service,” in Emotions and Social Movements, Flam

King

, eds. London: Routledge, 145–149.

54.

Sweeney

Jillian C.

Danaher

Tracey S.

McColl-Kennedy

Janet R.

(2015), “Customer Effort in Value Cocreation Activities: Improving Quality of Life and Behavioral Intentions of Health Care Customers,” Journal of Service Research, 18 (3), 318–335.

55.

Thévenot

Laurent

(2001), “Pragmatic Regimes Governing the Engagement with the World,” in The Practice Turn in Contemporary Theory, Knorr-Cetina

Schatzki

Savigny

E. V.

, eds. London, UK: Routledge, 56–73.

56.

Thornton

Patricia H.

Ocasio

William

Lounsbury

Michael

(2012), The Institutional Logics Perspective: A New Approach to Culture, Structure, and Process. Oxford, UK: Oxford University Press.

57.

Thornton

Patricia H.

Ocasio

William

(2008), “Institutional Logics,” in The Sage Handbook of Organizational Institutionalism, Greenwood

Oliver

Suddaby

Sahlin-Andersson

, eds. Thousand Oaks, CA: Sage, 99–128.

58.

Vargo

Stephen L.

Lusch

Robert F.

(2016), “Institutions and Axioms: An Extension and Update of Service-Dominant Logic,” Journal of the Academy of Marketing Science, 44 (1), 5–23.

59.

Vargo

Stephen L.

Akaka

Melissa Archpru

(2010), “Service-Dominant Logic,” Review of Marketing Research, 6, 125–167.

60.

Vargo

Stephen L.

Lusch

Robert F.

(2004), “Evolving to a New Dominant Logic for Marketing,” Journal of Marketing, 68 (1), 1–17.

61.

Vijay

Devi

Monin

Philippe

Kulkarni

Mukta

(2020), “Strangers at the Bedside: Subaltern Solidarities and New Form Institutionalization,” in 80th Academy of Management Proceedings, Atinc

, ed. https://doi.org/10.5465/AMBPP.2020.239.

62.

Vijay

Devi

Whitelaw

Sandy

Clark

David

(2020), “Logic Conflicts in Community-Based Palliative Care,” Progress in Palliative Care. doi: 10.1080/09699260.2020.1817691

63.

Vijay

Devi

Monin

Philippe

(2018), “Poisedness for Social Innovation: The Genesis and Propagation of Community-Based Palliative Care in Kerala (India),” M@n@gement, 21 (4), 1329–1356.

64.

World Health Organization (2020), WHO Definition of Palliative Care. (accessed January 20, 2020), [available at https://www.who.int/cancer/palliative/definition/en/].