Negotiating conflicting roles: Female community health workers in rural Rajasthan : - a perspective on the Indian ASHA-programme

The "ASHA", a female community health worker, is the newest addition to India's frontline government health workers. This community health worker programme is embedded in the state health services, with a focus on maternal and child health, and family planning. They are named the "Accredited Social Health Activists" (ASHAs). Through the guidelines for selection of ASHAs and the North Indian kinship system, the ASHAs are young women, married into the village community they serve. The ASHAs are to facilitate the use of state health services in pregnancy, delivery, family planning and children's health care and to bring awareness to their community about the state's health advices and health schemes through mobilisation, counselling and creating awareness. The thesis is based on 6,5 months of field work in North India, including five months of living in the village household of an ASHA in Rajasthan. The aim of the thesis is to explore the social interface between ASHAs and their village community and the public health system, how they negotiate between their various social roles. In order to do so, I contextualise and describe the dynamic social structures within which they manoeuvre and I explore the agency available for them. Various aspects of the ASHAs' position and agency is explored, mainly through the lens of a family planning campaign and the events that unfolded in the promotion, and execution of the campaign. This case-story illustrates that ASHAs meet conflicting pressures, and have to manage conflicting roles and duties - to health superiors, to their own household and to the rest of the village. I argue that they occupy an ambiguous and vulnerable position at the frontline and examine how they, skilfully, manage and navigate their role and work in order to perform well with regards to government criteria and, yet, also maintain good relations within the village. The ASHA-programme, moreover, represents a current governing "technology" of the Indian state to induce behavioural change in the rural population's health practices. Thus the thesis is also a local study of the changing interface between the State and its citizens - of ongoing governing technologies and modernity and citizenship discourses - through the lens of government health work. Erratum. Chapter 7 Appendix, page xi, second sentence should be: For all of the work for the ICDS, the ASHA-Sahyoginis are paid 500 fixed monthly rupees, there are no paid-for-performance incentives