Methodological Rationale

2This paper is based on research conducted during the months of August 2022, and January to March 2023. I primarily relied on qualitative research methods such as interviews and ethnographic fieldwork during this research. Qualitative research ‘is an inquiry process of understanding a social or human problem, based on building a complex, holistic picture, formed with words, reporting detailed views of informants, and conducted in a natural setting’ (Creswell, 1998, pp. 1–2). One of the reasons I gravitated towards qualitative research for this study was because, as Creswell (2007) articulated, qualitative research allows researchers to embrace the idea of multiple realities. The researchers, the participants in the research, and the readers as well, are all engaging with the work within their different subjective realities. Qualitative data collection also allows for participants to speak more freely in their own voice without the constraints of quantifying or summarising their experiences or thoughts (Berg, 2004). The use of qualitative data also allows us to more closely examine the ‘how’ and ‘why’ of what is being shared (Silverman, 2011). For a study like this, which examines how women negotiate and claim their spaces within tenuous employment frameworks; drawing on methods which allow for different narratives to co-exist and create multiple interpretations was important. An interview based approach, with semi-structured interviews and informal conversations serving as the primary mode of data collection, allowed for a proliferation of rich data and reflections which would not have been possible otherwise (Magnusson and Mareck, 2015).

3This research also included ethnographic observation, though of course not as time intensive as ethnographies usually are, given the constraints of doing this paper in a shorter period of time. I mainly spent my time in the Anganwadi centres and the neighbourhood dispensary, which allowed me to observe the daily interactions of the ASHAs and the community health ecosystem, as well as understand how their days are structured, the tasks expected and so on. Beyond this however, this short stint of ethnographic fieldwork also allowed for more familiarity between myself and the ASHAs and Anganwadis. As they saw me on a regular basis, we began having short informal conversations and greetings, and they also became more open to talking to each other in my presence. As a non-participant observer, I was nonetheless able to slowly become a part (in a sense) of this aspect of their daily lives. Furthermore, ethnographic observation also allows for what Clifford Geertz called ‘thick description’ (Geertz, 1973), which explains not only actions but the cultural meanings behind them. Observing the subtle ways in which the hierarchy between the ASHAs and Anganwadis was constructed and maintained for example, is imbued in structures of age, kinship, and authority.

Entry into the Field

4In August 2020, I interned with the Centre for Health and Social Justice (CHSJ) in New Delhi, India - a relatively small NGO with different areas of focus in the broad ambit of public health policy. More specifically, I was working with the CHSJ unit that was responsible for sexual and reproductive health rights (SEHER). During this time, I was part of a research project that was at the time conducting interviews with frontline health workers and young women in rural parts of India to assess the efficacy of healthcare facilities during the COVID-19 pandemic.

5The research work and interviews I did during this internship eventually led to the conceptualisation of my thesis project. When deciding how to conduct fieldwork, therefore, I decided to reach out to CHSJ once again. My previous supervisors at CHSJ were extremely supportive and extended help in the form of initial contacts with ASHAs and an entry point into the field. This meant that I would be conducting fieldwork in the peri-urban parts of Delhi, as this is largely the geographical area of focus for CHSJ. While the ASHA scheme is much more widespread in most rural areas of India, as opposed to urban areas, Delhi is one of the few exceptions to this case. The urban ASHA scheme was piloted in Delhi in 2014 and since then has expanded to large numbers within the National Capital Region, making Delhi an extremely viable site for this research.

6In August 2022, I spoke at length about my research with the coordinators of SEHER. As I was in Delhi at the time, it was suggested that I could go to their area of work and speak with some of the ASHAs, to see if this project would be viable. SEHER has an office space in Janta Mazdoor Colony, an area in the Shahdara district of Delhi. On that first day in August, I met not only two of my initial interviewees, but also the people who would become my primary interlocutors. Meena and K. are two residents of Janta Mazdoor Colony, who are employed by SEHER as field workers. As residents, they have strong connections with the people in the area, and usually are out the entire day conducting surveys and helping the frontline health workers in their daily rounds. Meena was the one who first got us in touch with the ASHA workers. Slightly older than myself, she has lived in the area for over ten years, having moved to Delhi from Chandigarh after her marriage. Two of the ASHAs, Disha-di and Sunita-di, are her friends as well as colleagues, in a way.

7Before moving further, I will take this space to address the ways in which I and my interlocutors referred to one another. I always referred to Meena as Meena-di. Di here is a shortening of the term ‘didi’ which means older sister in Hindi and other North Indian languages. She and K. also called me ‘di’ despite the fact that I was younger than at least one of them. Similarly, all the ASHAs I met were addressed, and addressed me as ‘di’ as well. I primarily followed Meena-di’s lead on this, taking note of how she addressed the ASHAs and then following suit. Sometimes, they referred to each other as ‘behenji’ (behen means sister in Hindi and ji is a commonly used honorific), but usually defaulted to the suffix ‘di’. Such terms are commonly used among non-kin, often to signify respect. In her reading of fictive kinship structures in urban North India, Sylvia Vatuk also explores how the common use of ‘sister terms’ encapsulates multiple relations of non-kinship, which are nonetheless based on social ties such as neighbourhoods, relative age, proximity of the two individuals in question and so on:

[T]he significant point here is that this reciprocal usage begs the question of relative age, and therefore of seniority, which is important throughout the Hindi kinship terminology.[...] It may also be said that reciprocal use of the ‘sister’ and ‘brother’ terms suggests a shift in social meaning (in the context of fictive kinship) from seniority to respect, a respect that is mutual in its application. (Vatuk, 1969, 268)

8The first day I met her, Meena-di told me about how Disha-di had helped her enormously during her first pregnancy. As a new mother in a foreign city, she spoke at length about how nervous she had been and how having an ASHA to guide her throughout the pregnancy period was a source of comfort for her. When Disha-di arrived at the office, both of them spoke of that time, and of how they had become friends during and after that period. Meena-di stayed in the room for the course of the interview, and occasionally chimed in herself.

9This initial period went well, and both Meena-di and the ASHAs present said that they could help in connecting us to other ASHAs and getting more interviews. Based on this, I had a further discussion with the researchers at SEHER and we decided on a collaborative agreement for this research. It was decided that SEHER would help me gain entry into the field and connect with participants for the research, and I would in turn help the organisation to streamline and improve their efforts to engage with frontline health workers in the area in a more fruitful manner through the findings of my research.

10The next phase of research took place in January and February 2023, when I returned to Delhi specifically for this fieldwork. During this time, I interviewed six ASHA workers, four public health professionals, and four Anganwadi workers, leading to a total of 15 interviews with 14 participants over the course of approximately 11 weeks. The pool of interviewees was as much a conscious choice as it was a matter of circumstance and chance. Earlier in the year I had considered speaking to public health professionals as well, in order to gain a better understanding of state-ASHA relations. However, given the paucity of time, as well as the themes that were emerging from my initial interviews, I thought that it would be equally fruitful to speak mainly to ASHA workers. However, certain challenges arose during fieldwork which led me to go back to my original ideas.

11Primarily, it was difficult to find time to talk to the ASHA workers. Their busy schedules and lack of availability over call led to many days without interaction. It was at this time, around the beginning of February, that I began to worry about this as I felt that I would not obtain enough data for my paper. However, this challenge also presented the opportunity to go back to my earlier ideas for fieldwork and reach out to other people who may not be ASHAs themselves, but work closely with them, often fill in for them, or have been involved in the very policy-making process of the ASHA scheme. Therefore, I began talking more to the Anganwadi Workers in the area, who were generally more available.

12Anganwadi workers have appointed centres: in the case of Welcome Colony in Seelampur district, these centres tend to be small rooms covered with colourful rugs and posters on appropriate child nutrition, check-up timings, vaccination dates and so on. The Anganwadi workers generally stay in their centre, with a few children filtering in throughout the day. As Anganwadis are directly above ASHAs in the community health scheme, they work with them on almost all matters. However, the labour structure of Anganwadis and ASHAs, as will be discussed further, is different, which led to some interesting insights through my conversations. Further, this hierarchy between the Anganwadis and ASHAs meant that as my familiarity with the former increased, they were confident in telling the ASHAs they knew that it would be good to talk to me. My affiliation with a reputed NGO in the area also helped matters.

13Second, I decided to go back to the idea of interviewing public health professionals. I was able to get interviews with some experts who had been involved in implementing the initial phase of the ASHA scheme and making key contributions to the NRHM in 2004. These conversations also allowed me to engage better with the themes of state-labour relations that I felt could be built upon in my further research.

14Interviews were conducted with the help of an interview schedule that was drawn up prior to conducting the initial interviews in January and February. As more interviews were conducted, questions in the schedule were removed, added, or modified as seen fit at the time. Furthermore, I developed two interview schedules: one that I used in my interviews with ASHA workers and one that was for interviews with public health policy makers. Both schedules had approximately 20 questions, which were divided into thematic categories which will be explained further. However, I did not use the schedule as a strict guideline but more as a reference point. The questions were asked in a way that flowed with the rest of the conversation, and at many points the interview deviated from the schedule in terms of anecdotes shared, certain themes the participants focused on more, etc.

15The interview schedule for the ASHAs consisted of the following sections:

1. Introductory questions: demographic details

2. Recruitment and training phase of ASHA work

3. Workload: daily schedules, main tasks

4. Relationships with the community

5. Reflections on being an ASHA

16For the interviews with the policy makers, the schedule derived mainly from the data I collected while talking to ASHAs. We also spoke in detail about the policy-making process, and about community health programmes in India in general.

17A complex part of the research was how to address sensitive questions of caste and class with the ASHAs. Addressing the extremely intricate and complicated impact of caste systems on the ASHA scheme and individual workers may perhaps be out of the scope of this study, but definitely provides avenues for further research. The issues of caste hierarchy and caste politics did come up in overt ways throughout the course of the interviews and fieldwork, but were not always directly asked. The participants themselves did not encourage or respond to direct questions of caste positively, but would often allude to caste-based practices and identity, for example, serving tea to me and Meena-di in different cups.1 In Seelampur, the religion aspect was also key and it was difficult to ignore the fact that the only ASHAs in a Muslim-concentrated neighbourhood were all Hindus. However, direct questioning along this line did not often lead to insights, as most ASHAs simply said that there were no Muslim ASHAs because of a lack of education for women in the community. Raising such topics directly through questions does not always prove fruitful (Sreerekha, 2014), which is yet another reason that observation was such a key part of my research process.

Ethnographic Fieldwork

18Apart from interviews, I also conducted ethnographic fieldwork. As mentioned before, the ASHAs were extremely busy with a vaccination camp for rubella in the area. These vaccination camps were held in the various Anganwadi centres in the colony, with each level of the community health workers present and having an identified role. The Anganwadi workers were responsible for record keeping and the Anganwadi helpers maintained the order and generally assisted in overseeing a smooth process each day. The ANMs were responsible for the actual administration of the vaccine, and the ASHAs were in charge of rounding up the children in the area and informing their parents about the vaccination. This included giving them the basic information about the vaccine, what it would prevent, why it was necessary for children to get this vaccine, potential side effects, the age limit and so on. Due to this extensive work for over three weeks, it was very difficult for them to make time to speak to me on a one-on-one basis, and I also did not feel comfortable imposing myself on their work schedule when they clearly had much to accomplish within a short period of time.

19Therefore, Meena-di and I decided to visit each of the vaccination centres and see whether it would be possible for us to sit and observe the process. Another site for observation was the local clinic or dispensary, referred to by most as the double-storey dispensary. Located on the other side of the main road, in Welcome Colony instead of Janta Mazdoor Colony, it was a large building with a waiting area and small rooms on either side of the corridors within it. I initially went there to establish contact with the local doctors and potentially be introduced to some ASHAs in the area. Armed with a letter of reference from SEHER, I was led to the doctor’s office, where two doctors were sitting and conversing with each other. After a while, they turned to me and allowed me to explain my research to them. When I said I wanted to speak to the ASHAs, they cut me short and told me to talk to the ANM as she worked closely with them and would be able to help me better.

20The ANM sat in a separate room a little further away, with a long line of parents with their infants and toddlers waiting for her. She told me to sit on the chair while she spoke to the parents. When I visited the dispensary later, I was again allowed to sit and observe for a few hours, which I did for a couple of days each week. The interactions and social relations witnessed at the dispensary - whether between the ANM and the doctors, the ASHAs and ANMs, medical personnel and community health workers, or the public, proved to be very interesting grounds for observation.

Ethical Considerations

21It was communicated to all participants that these interviews were being conducted primarily for the purpose of this thesis. I introduced myself to the ASHAs and community health workers as a student researcher who was collaborating with SEHER, an NGO in the area which focused on women’s health. At this stage, I made it clear that I would like to interview the ASHAs and ask them some questions about their work, difficulties they were facing, and other aspects of being an ASHA that they would like to talk about. I also asked whether they would prefer to remain anonymous or if they were all right with being named in the research. I specified that this was for a research project that I was conducting independently. However, I also articulated that my collaboration with SEHER meant that I would share my research findings with them, which would in turn allow the NGO to further assist the ASHAs in the area in a more focused manner. While most of the ASHAs seemed willing to help a student researcher, they were also keen to get their concerns voiced in front of NGOs in the area, as this would help their situation as well.

22All participants were also asked beforehand whether they were comfortable with having the interviews recorded. If they agreed, the interviews were recorded via my phone, and were later translated and transcribed manually. Most participants however, specifically the ASHAs, did not want the interviews to be recorded. In these cases, I took notes manually during the interviews whenever possible. I also wrote down immediate reflections after the interview, to ensure that I was able to retain as much information as possible. In some cases, I also took audio recordings of myself after the interviews, when there were particular phrases or sentences I wanted to remember and translate later. The names of participants have been changed for anonymity purposes, or have not been mentioned, as requested by them during the interviews.