4.3 Key themes from the Ethnographic Methods
The ethnography identified or supported a number of themes that are important for Project RISE’s goals and that are visited repeatedly in subsequent chapters. These include the importance of support, the ‘doubly powerless’ nature of the ASHA, and the complex nature of her role.
The ethnography made numerous observations on the importance of familial support for increasing ASHA efficacy, or at least in the potential for support to be valued as she carries out her duties. Husbands and daughters often helped with ASHA duties, either directly, as in the case of a husband providing transport or completing paper work, or indirectly, as in the case of daughters helping to manage the household while the ASHA works.
For example, one ASHA joked that her husband is more popular than her at the PHC, and really seems to appreciate his help. She said that after she is done with her patient at the hospital and returns home her husband does all the paper work afterwards, such as getting birth certificates issued, and filing the form for payments.
ASHAs also benefit from support from other ASHAs or from ANMs. ASHAs often communicate with each other for help, but have occasional conflicts in terms of catchments (the quantitative data suggests these conflicts are rare). ASHAs are comfortable communicating with each other using handheld devices.
Conversely, the lack of support from medical staff and doctors may hamper ASHA effectiveness.
And of course ASHAs feel the lack of support as well. For example, one ASHA was observed serving food to her husband. She then washed his plate before getting a plate for herself, which she does while while on her cellphone trying to reach pregnant mothers in her catchment area whom she is supposed to take to the PHC for ANC. After her husband finished eating his lunch and when she finally sits down with her’s, the husband turns to her and says “the food doesn’t taste too good today.” Then while eating, she gets two calls but because the reception isn’t clear she has to get up from eating twice during her lunch go outside for better reception.
Related to support but also speaking to the way that her embeddedness creates unique tensions between her personal and professional roles, the ethnographic effort also noted that an ASHA’s social status and feelings of self-worth require that she maintain a highly functional household while also completing her duties.
4.3.2 Doubly powerless
The ethnography also concluded that the ASHAs were in a situation of “double-powerlessness,” referring to a kind of “squeeze” from a lack of autonomy and social status due to age and position. The majority of ASHAs and beneficiaries are from the same wide age range, 25 to 45, but within this range ASHAs tend to be older than the mothers they provide service to. In the home, women in this age range gain some status with age but this age-group has the highest expectations for work. Older women, mothers-in-laws, have much more status in the home, accrued in part due to experience and the number of children raised.
Double-powerless also affects an ASHA’s community interactions, in dealing with hierarchies based on gender or generation on a regular basis.
Later phases of Project RISE found that this notion of being “squeezed” or doubly-powerless is part of the connective nature of the ASHA’s role. She is between worlds in many ways. A challenge for further analysis and as a consideration for co-design is the degree to which being doubly powerless is reinforced by any community rituals or is strictly normative, or both.
An illustrative quote from the ethnography: >“The ASHA’s identity as a trained frontline health worker and her identity as a member of the community, immersed in its culture, appeared entangled, giving rise to unique ways of interpreting and adapting medical advice meant to be shared with new mothers in the community.”
This observation was reinforced by later synthesis and discussion by the Project RISE team and motivated our conceptual approach to framing the tensions that ASHAs face (see Figure 2.2).
4.3.3 Being in Between
We are describing a challenge of the ASHA’s role as being between worlds because she is so often a threshold or connection between two communities or systems, without being fully in either one at a given time. This occurs often in connecting beneficiaries with the health care system, as the ASHA is not seen as being a part of the household, as the Dai is, nor is she formally a part of a hospital’s medical staff. (Note, being ‘in between’ does mean the same thing as being doubly powerless as betweenness is about connecting and representing a boundary and doubly powerless is about the squeeze in status as a function of norms attached to age. The power dynamics could be different at any given locus of connection.)
In the ethnography we have cases of being in between as a fundamental aspect of the ASHA’s role in, at least, the following contexts: * connecting a beneficiary to the medical system * once in the medical system, navigating the structure and red tape within it * the space between the government and private health care systems (Excerpt 1, above) * the boundary or tension between traditional and biomedical belief systems (Excerpts 2 and 3, above).
Being an ASHA involves constantly going from a few highly cooperative and appreciative settings to many highly antagonistic and dismissive ones.
Here and in all other datastreams we see evidence that ASHA motivation is not as simple as a need for incentive payments, nor is it strictly a drive to serve her community. In most cases it is a mixture of both and the two may even interact. The ASHAs often mentioned that they cannot support their households on the incentives alone, but also that the annoyance of the paper work and the frequent delays and under-payments affected their motivation.