2020, 2021
Vrinda Marwah
- Emerging Voices Fellow
- University of Utah
Abstract
Working in the heart of India’s reproductive health care system, this project explores how the contemporary state constitutes citizenship through the modality of care. It examines the working lives of women community health workers, called ASHAs, who are “volunteers” paid to motivate poor women to use public health services. ASHAs reveal the productive power of an understudied and intensely gendered role in the state: the frontline bureaucrat. Because of the deeply intimate knowledge ASHAs have of their clients, and the networks they build among public and private health care providers, they become highly sought-after actors in service delivery. Through 14 months of ethnographic fieldwork, this project uncovers how the sociality of these women exceeds, and reconstitutes, the policy they are meant to implement.
Dissertation Abstract
"Reproducing the State: Women community health volunteers in North India"
My dissertation uses 14 months of ethnographic fieldwork (2018-19) with women community health workers in north India, mainly Punjab, to theorize statist power, gendered disempowerment, and the kind of agency that emerges at their intersection.
Women community health workers are at the frontlines of health care provisioning. In low- and middle-income countries, these workers connect the poor and marginalized to health systems. India’s community health worker program is the largest in the world. Its one-million strong, all-women workforce is a success story. Since their appointment in 2007, these ASHAs (Accredited Social Health Activists) have spearheaded significant improvements in the country’s reproductive health outcomes. However, ASHAs are an exceptionally precarious workforce. They are “paid volunteers”, who receive none of the benefits of staff, and get per-case “incentives” instead of salaries. These poor and mostly lower caste women work round-the-clock in an under-resourced and over-burdened health system, for an itinerant pay that is a fraction of minimum wage. Given these conditions, I ask, how do ASHAs succeed in delivering health services? What does their success tell us about state power?
In the first chapter, I show how ASHAs’ liminal occupational status as “incentivized volunteers” is a new way for states to devalue paid care work. Incentives exist for a fraction of the work ASHAs do, rendering vast amounts of their labor invisible. Moreover, by withholding or threatening to withhold incentives, the health department exerts disproportionate control over ASHAs. When ASHAs try to claim fair and timely pay, the gendered idea of a “selfless” volunteer is used to deny them their due. An article based on this chapter was awarded second place by the 2021 Audre Rapoport Prize in Gender and Human Rights. In the second chapter, I follow ASHAs into their communities. To secure patients, ASHAs perform what is usually represented as “gossip” but what I call “motivational labor”, that is, they forge and sustain intimate relations with other women in their communities. I find upper caste women have more “motivational capital” and do less “motivational labor” than their lower-caste counterparts, but the relational nature of caste means that the lower-caste ASHAs accrue more status gains from motivational labor (most families that rely on public health are lower-caste). I also argue that the care work of ASHAs comprises political socialization; ASHAs teach themselves and other women how to navigate the state, such as accessing welfare schemes, thus maintaining state legitimacy from below. In the third chapter, I show that paid care work can carry economic rewards. The sociological literature on paid care work emphasizes economic penalties. However, I find that ASHAs use their expanded social networks to earn additional incomes, through side hustles and commissions that private clinics give ASHAs for referring patients. I also show that the intrinsic rewards ASHAs experience in paid care work—flexibility, skill building, emotional gratification—are tied inextricably to their earnings. This calls into question the “Love versus Money” binary, used to frame much of the discussion on care work. An article based on this chapter won the Best Graduate Student Paper Award 2021 from the Global Division of SSSP, and has been accepted to Social Problems.
However, rewards are not all that keep ASHAs in their role. In the fourth chapter, I discuss what I call the ‘promissory capital’ of the Indian state. Women become ASHAs because they believe the role is, or will become, a permanent government job. And while this has not happened, the state keeps promise alive by making small overtures to ASHAs. I show how a hollowed-out state nonetheless attains legitimacy in the eyes of its workers. An article based on this chapter is forthcoming in Qualitative Sociology. In my fifth and final chapter I scrutinize the ecology of health delivery in India. I draw attention to the ways in which the private sector is embedded in the public sector, and how ASHAs’ private hospital links are encouraged, even required, by how the public health system is organized. My findings trouble the easy narrative of success that has come to be associated with the ASHA program. I raise concerns about the neo-liberal iteration of the community health worker model, at a time when it is being touted by international organizations as the answer to health system woes.
My dissertation uses 14 months of ethnographic fieldwork (2018-19) with women community health workers in north India, mainly Punjab, to theorize statist power, gendered disempowerment, and the kind of agency that emerges at their intersection.
Women community health workers are at the frontlines of health care provisioning. In low- and middle-income countries, these workers connect the poor and marginalized to health systems. India’s community health worker program is the largest in the world. Its one-million strong, all-women workforce is a success story. Since their appointment in 2007, these ASHAs (Accredited Social Health Activists) have spearheaded significant improvements in the country’s reproductive health outcomes. However, ASHAs are an exceptionally precarious workforce. They are “paid volunteers”, who receive none of the benefits of staff, and get per-case “incentives” instead of salaries. These poor and mostly lower caste women work round-the-clock in an under-resourced and over-burdened health system, for an itinerant pay that is a fraction of minimum wage. Given these conditions, I ask, how do ASHAs succeed in delivering health services? What does their success tell us about state power?
In the first chapter, I show how ASHAs’ liminal occupational status as “incentivized volunteers” is a new way for states to devalue paid care work. Incentives exist for a fraction of the work ASHAs do, rendering vast amounts of their labor invisible. Moreover, by withholding or threatening to withhold incentives, the health department exerts disproportionate control over ASHAs. When ASHAs try to claim fair and timely pay, the gendered idea of a “selfless” volunteer is used to deny them their due. An article based on this chapter was awarded second place by the 2021 Audre Rapoport Prize in Gender and Human Rights. In the second chapter, I follow ASHAs into their communities. To secure patients, ASHAs perform what is usually represented as “gossip” but what I call “motivational labor”, that is, they forge and sustain intimate relations with other women in their communities. I find upper caste women have more “motivational capital” and do less “motivational labor” than their lower-caste counterparts, but the relational nature of caste means that the lower-caste ASHAs accrue more status gains from motivational labor (most families that rely on public health are lower-caste). I also argue that the care work of ASHAs comprises political socialization; ASHAs teach themselves and other women how to navigate the state, such as accessing welfare schemes, thus maintaining state legitimacy from below. In the third chapter, I show that paid care work can carry economic rewards. The sociological literature on paid care work emphasizes economic penalties. However, I find that ASHAs use their expanded social networks to earn additional incomes, through side hustles and commissions that private clinics give ASHAs for referring patients. I also show that the intrinsic rewards ASHAs experience in paid care work—flexibility, skill building, emotional gratification—are tied inextricably to their earnings. This calls into question the “Love versus Money” binary, used to frame much of the discussion on care work. An article based on this chapter won the Best Graduate Student Paper Award 2021 from the Global Division of SSSP, and has been accepted to Social Problems.
However, rewards are not all that keep ASHAs in their role. In the fourth chapter, I discuss what I call the ‘promissory capital’ of the Indian state. Women become ASHAs because they believe the role is, or will become, a permanent government job. And while this has not happened, the state keeps promise alive by making small overtures to ASHAs. I show how a hollowed-out state nonetheless attains legitimacy in the eyes of its workers. An article based on this chapter is forthcoming in Qualitative Sociology. In my fifth and final chapter I scrutinize the ecology of health delivery in India. I draw attention to the ways in which the private sector is embedded in the public sector, and how ASHAs’ private hospital links are encouraged, even required, by how the public health system is organized. My findings trouble the easy narrative of success that has come to be associated with the ASHA program. I raise concerns about the neo-liberal iteration of the community health worker model, at a time when it is being touted by international organizations as the answer to health system woes.