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Liminality as wage penalty for India’s women community health workers

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Vrinda Marwah discusses the experiences of the world’s largest all-women community health workforce through the lens of liminality.

Image courtesy of interviewee. September 23, 2024

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This video discusses the concept of liminality, primarily in the context of work and occupations, drawing on anthropological theories from Arnold Van Gennep and Victor Turner. Liminality refers to transitional states characterized by uncertainty and marginalization, often seen in rites of passage. The speaker is particularly interested in applying this concept to labor dynamics, especially regarding the rise of non-standard employment such as gig and contract work.

The speaker highlights the experiences of a specific group of workers in India — Accredited Social Health Activists (ASHAs), a workforce of around one million women responsible for community health services. Despite their significant contributions, ASHAs are classified as volunteers rather than workers, which undermines their legitimacy and leads to chronic underpayment and lack of worker rights.

The speaker's ethnographic research in Punjab reveals systemic issues, including confusion over incentive payments tied to their work, which often leads to delays or denials. ASHAs are subjected to additional pressures and control from supervisors, illustrating how their liminal occupational status further exacerbates their vulnerability.

Ultimately, the speaker argues for the need to reclassify ASHAs as workers and ensure fair pay. They emphasize that understanding how wages are structured is as crucial as the amounts being paid, pointing out that the institutionalization of informal labor practices is contributing to the worsening gender wage gap in India's public health sector. The need for fair labor practices is not just about justice for these workers but also about improving overall health outcomes in the communities they serve.

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Here are five key points from the video regarding the concept of liminality and its application to work, particularly focusing on community health workers in India:

1. **Concept of Liminality**: Liminality, originally an anthropological concept, describes a transitional state where individuals are separated from their familiar group, leading to uncertainty but also the potential for creativity and transformation, as seen in rites of passage.

2. **Non-Standard Employment Trends**: The speaker discusses the rise of non-standard employment types (like contract and gig work), questioning the implications of liminality in this convideo. They explore when liminality can be beneficial for workers and when it exacerbates marginalization and exploitation.

3. **Liminal Position of ASHA Workers**: The research specifically investigates the plight of ASHA (Accredited Social Health Activists) workers in India, who occupy a liminal occupational status as "paid volunteers." They are tasked with important health roles but are classified in a way that undermines their rights and pay, often leading to wage penalties and lack of recognition as formal workers.

4. **Control Through Incentive Structures**: The incentive system for ASHA workers is both a form of payment and a mechanism of control exercised by the health department. The structure not only leads to confusion and denial of incentives but also allows supervisors to exert pressure on workers to complete additional non-credentialed tasks.

5. **Impact on Gender Wage Gap**: The study highlights how the liminal status of ASHA workers contributes to the broader issues of gender wage disparity and devaluation of care work, underscoring the need for fair wages and recognition of workers’ rights as essential for effective health outcomes and social justice.

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Here are key quotes from the video , highlighting the main concepts and findings:

1. **Definition of Liminality:**
- “The concept of liminality comes from anthropology, specifically from the work of Arnold Van Op and Victor Turner.”
- “Liminality describes a rite of passage in which an individual is sort of removed from a familiar group and is put through a liminal space that's characterized by uncertainty.”

2. **Liminality in Work:**
- “So the conversation in the scholarship is, you know, when is liminality in the world of work? When is it a good thing? When is it creative? And when is it a bad thing?”
- “Maybe liminality is something that powerful professions are able to use to their advantage, but subordinated professions are not able to use to their advantage.”

3. **Care Work and Gender:**
- “Care is gendered work. It's considered a social obligation, um, of women, really something that women are supposed to do.”
- “We already know that care work occupations carry a wage penalty.”

4. **Feminization of Obligation:**
- “What they're doing is they're not classifying these women as workers workers... they’re paying them very nominal stipends.”
- “The Indian state is relying more and more on extremely underpaid women workers to deliver programs in health, in education, and in nutrition.”

5. **ASHA Workers:**
- “ASHA's are the community women who have about eight years of education... their job really is to connect their communities, which are marginalized communities through state health services.”
- “Ashas are appointed in this liminal occupational category of a paid volunteer... they're considered volunteers.”

6. **Payment Structures and Control:**
- “Incentive payments were very often denied to ASHA's. So even if they've done the job, there is oftentimes genuine confusion about how an incentive should be paid.”
- “Incentives become leverage... it becomes very easy for the health department to say, um, you know, we won't give you this payment till you do this other thing.”

7. **Impact of Liminal Status:**
- “Their liminal occupational status really erodes ASHA's legitimacy as workers.”
- “There's a crisis of credibility... they don't have rights as workers that are recognized.”

8. **Recommendation for Fair Wages:**
- “At the very minimum, they need to be employed with the rights of workers.”
- “The conditions under which health workers work matters very much for health outcomes.”

9. **Conclusion on Gender Wage Gap:**
- “It's not just that the wage is low, it is that you have a system that creates conditions for chronic underpayment and control.”
- “I think it's a new way in which the gender wage gap is being further lowered... the devaluation of care is being institutionalized.”

These quotes encapsulate the main themes of the research on liminality in the workforce, with a specific focus on the experiences of ASHAs in India and the implications of their occupational status on wages and rights.

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The concept of liminality comes from anthropology,

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specifically from the work of Arnold Van

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Op and Victor Turner.

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And they use liminality to describe, a state

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that's transitional.

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And that's in between, something that's been assigned

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by custom conventional law.

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So think of it this way, in its original usage,

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liminality describes a rite of passage

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in which an individual is sort

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of removed from a familiar group

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and is put through a liminal space that's characterized

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by uncertainty, by separation, right?

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And eventually the reincorporated to the group.

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Um, and the second liminal stage is the stage

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that's kind of, it's painful.

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It's, it's, it's temporary,

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but of course it's made bearable

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because, you know, the individual has the support

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of the group, you know, it's temporary,

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and you also know that you're coming out on the other side,

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sort of from a child to an adult, right?

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So in its anthropological usage, liminality is,

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is both marginal, but it's also creative.

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And this concept has a very rich history.

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It's been used by lots of scholars

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and lots of, ways

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to describe contemporary social phenomena.

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It's also been critiqued it as being too kind

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of male-centric or to status coist or whatever.

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Um, in my work,

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however, I'm interested in how liminality is applied

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to the study of work and occupations.

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So we know that over the last couple of decades,

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the world has seen a huge rise in what's called

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non-standard employment.

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So contract work, temporary work, gig work

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that departs in really fundamental ways from

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full-time permanent work.

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So the, the conversation

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and the scholarship is, you know,

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when is liminality in the world of work?

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When is it a good thing? When is it creative?

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And when is it a bad thing?

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When does it only create, you know, problems

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and more marginalizations for workers?

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So that's kind of, that's kind of the, the strand

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of scholarship that I'm interested in.

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And I'll give you one example of this debate in,

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in the scholarship.

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So, for example, some scholars use the term professional

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hybrid to describe, people with professional backgrounds

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who also do managerial roles.

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So think about, doctors

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who also become hospital administrators.

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And the research finds actually that they're able

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to occupy these positions, quite well,

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that doctors are able to be both professionals and managers,

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and they're able to grow their status

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and grow their prestige.

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You know, in, in both these groups, they move

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between them with a lot of ease.

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So this literature tells you

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that liminality is a positive experience,

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but then there's further research on the experience

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of nurse hybrids,

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and it tells you actually that nurses do not enjoy,

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the same kind of power.

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They actually experience a lot

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of identity conflict when they have to move

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between their professional role and,

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and their management role.

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The way this conversation has advanced is to say

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that maybe liminality is something that

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powerful professions are able to use to their advantage,

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but, subordinated professions are not

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able to use to their advantage.

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So all this to say that the conversation on is liminality,

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good or bad for workers, is an ongoing one.

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And I think we, we kind of need more research on

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what it means, for all kinds of workers, right?

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Not just for one kind of worker.

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My research looks at a frontline health workforce in India.

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Uh, community health workers right now,

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frontline health workers are a type of care worker.

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And scholarship already documents a wage penalty in

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care, alright?

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And the idea here is that care is, is gendered work.

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It's considered a social obligation, of women,

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really something that women are supposed to do,

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do naturally, you know, without boundaries in their homes

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and in their communities.

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So that is why care is devalued, considered,

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typically work that's worthy of good wages

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and good working conditions.

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So this is already very well documented

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that care work occupations carry a wage penalty.

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Now, a trend that you have in countries

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of the global south today is something that's scholars

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of gender and development are calling the

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feminization of obligation.

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So the idea is that states are appointing women

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to deliver public social services in roles

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that are quote unquote voluntary or honorary, right?

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And these voluntary and honorary roles, essentially

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what they're doing is they're not classifying these women

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as workers workers.

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So what's happening is,

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even though states are appointing them,

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states are training them, states are supervising them,

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states are not paying them wages,

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they're paying them very nominal stipends,

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and they're being able to sidestep labor

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obligations to these women workers.

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This is something that's been happening in

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India in a really big way.

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The Indian state is relying more

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and more on extremely underpaid women workers to deliver,

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programs in health, in education, and in nutrition.

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So my work looks at one such workforce, that's called

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ASHA's or accredited social health activists.

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And these are about 1 million women, all women,

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community health workers.

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And we already know that there's,

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we already know from quantitative research that,

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the state has increased the gender wage gap,

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in the public sector, you know, through these,

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through employing these women workers.

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So we already know that there's a, there's a wage penalty,

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and that the wage gap is increasing actually in the

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formal sector, in India.

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Um, and in fact, we know this, like I was saying

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to you about care work everywhere in the world.

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We know that care work carries a wage penalty.

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We also know that,

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non-standard work increases the gender wage gap

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because women are more likely than men

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to hold contingent jobs.

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So in, in quantitative terms, we already know

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that there is a, there is a wage gap

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Problem, and my research kind of, is an ethnography.

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So it adds a qualitative perspective to, to this,

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to the scholarship on the gender wage gap by asking how,

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how, how this, these kinds

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of working conditions are experienced by, by women in,

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in, in frontline health work.

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The workforce that I, I study,

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ASHA's accredited social health activists,

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they were first appointed

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by the Indian State in 2005, right?

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And they were appointed as a part of,

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something called the National Rural Health Mission,

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which was a flagship national program, that was supposed

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to expand health services.

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And one way that it did, this is

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by appointing community health workers.

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Now, ASHA's are the community women

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who have about eight years of, of education.

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They receive, you know, a couple of weeks of training.

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And their job really is to connect their communities,

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which are marginalized communities

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through state health services.

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And, ASHA's are appointed today, across rural India

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and in urban India, in in informal urban settlements.

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So the, the way ASHA's do this is through,

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home visits by keeping records,

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doing outreach services, et cetera.

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And they, they do this, specifically for maternal

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and child health and for immunization,

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but also for a range of other tropical diseases

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and non-communicable diseases

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and, you know, pandemic, control, right?

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With Covid, for example.

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Um, but at the, you know, to give you a picture of

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what they kind of do in the day-to-Day,

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Asha are monitoring the women

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and children in their neighborhoods,

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and they're kind of making sure that, the women

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and children are getting the vaccinations that they're due.

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If, if a woman is pregnant,

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that she's getting the medications

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and the checkups that she needs,

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and when it's time to give birth,

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that she gives birth in a hospital and not at home.

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This is kind of, you know, chiefly what the,

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what the work is.

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But what the state has done in keeping with the feminization

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of obligation that I was talking about earlier,

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what the Indian State has done is it's, it's a,

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appointed us in this liminal occupational category

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of a paid volunteer.

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So Ashers are not considered workers.

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Um, they're considered volunteers.

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Uh, and like I was saying, even though they are,

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appointed by the state and trained by the state

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and supervised by the state,

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and they put in on,

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most ass actually work more than 30 hours a week, right?

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So they're, they're doing a lot of work for the state,

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but the state doesn't owe them, a living wage.

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It only gives them stipends.

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And it also obviously doesn't have any other,

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doesn't have to give them any other kinda worker

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entitlements, like leave, et cetera, either, right?

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So, so this is,

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and remember I said that Asha were first appointed in 2005.

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So you are talking about a liminal occupational group

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that's pretty much at this point permanently liminal, right?

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Like this is liminality for them is not a,

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not a temporary state.

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They're not interns.

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There's no career progression to, you know,

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becoming a permanent asra.

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This is it. This is just how they've been appointed

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and this is how they're paid.

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Um, so my, my research looks at

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what the experience of, of liminality means for ahas in,

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in, in the day to day, right?

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And the, the way I went about my research was I,

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my field site is a district in,

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the Northwestern state, of Punjab.

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And the district is, called Moser.

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And I, I did about 12 to 14 months

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of ethnographic field work between, two months in 2017,

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and then, 12 months between 2018

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and 2019, most of it in a rural

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and urban block of Moar district.

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And essentially what I did was,

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because it was an ethnography, when I first went to Moar,

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I was just following Asher's, you know, following them,

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like I told you, as community health workers,

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they link their communities with the state health system.

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So I'm following them on both these ends.

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So I go with them to their communities when they do

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home visits, right?

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When they're doing, say, health camps,

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or they're having protests, you know,

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having their own meetings, all of that.

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But also when they're being trained in the health system,

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when they're servicing patients

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in the health system, all of that.

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So I'm following them on both these ends.

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And after I do that for a couple of months,

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I inter I start doing interviews and I interview 60 Ashers.

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And the way I sample them is I interview equal numbers

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of rural and urban Ashers

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and equal numbers of Dali, which is, you know,

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your formerly untouchable casts for so equal numbers of Dali

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and dominant caste Ashers.

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So that's kind of how I sample.

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I interview 60 Ashers, and

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after I interview the Ashers,

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I also interview an additional 20, kind

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of ASHA program experts.

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So, you know, activists

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and officials who are working on the Asher program at the

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district level, at the state level,

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and at the national level.

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And the idea there is to kind of, you know, you have the,

11:07.385 --> 11:08.565
the ASHA point of view,

11:08.865 --> 11:11.885
and then you're able to kind of trace the consonances

11:11.885 --> 11:14.245
and dissonances between that point of view

11:14.385 --> 11:17.045
and the view of the people who, you know, are,

11:17.265 --> 11:20.125
are planning the ASHA program,

11:20.305 --> 11:24.045
and are working on the ASHA programs, the incentives that

11:24.075 --> 11:26.125
that s are, are supposed to be,

11:26.235 --> 11:27.485
paid right for their work.

11:27.985 --> 11:30.245
Um, let me explain just very quickly

11:30.265 --> 11:31.885
how these incentives are structured, right?

11:32.385 --> 11:34.405
So the, like I was telling you,

11:34.405 --> 11:37.085
because ahas are, are not workers,

11:37.195 --> 11:39.125
they don't receive a monthly salary.

11:40.235 --> 11:43.045
ahas are asked to do a list of tasks, tasks,

11:43.045 --> 11:46.605
and against every task is a very small incentive.

11:47.065 --> 11:49.725
So when you complete the task, you get the incentive, right?

11:49.725 --> 11:52.005
That's the idea. Um, now

11:52.705 --> 11:54.645
The way you get the incentive is

11:54.645 --> 11:56.005
that you make a monthly report,

11:56.705 --> 11:59.085
and this monthly report, all the tasks

11:59.155 --> 12:02.365
that you list you've done in that month, they're validated,

12:02.365 --> 12:04.645
they're checked and validated by a nurse

12:04.745 --> 12:07.205
who supervises you, right?

12:07.785 --> 12:12.325
So only the tasks that the nurse

12:12.885 --> 12:14.685
validates, you know, get kind

12:14.685 --> 12:17.845
of total added up into your monthly payment.

12:18.505 --> 12:21.405
And the incentive is, is, is supposed to be kind of,

12:22.145 --> 12:23.725
you know, it, they say sometimes

12:23.725 --> 12:25.765
that the incentive payment structure is,

12:25.985 --> 12:28.125
has a fixed component and a variable component.

12:28.125 --> 12:30.965
It's actually kind of all variable. It's all against tasks.

12:31.385 --> 12:33.445
But there are some tasks that are very routine,

12:33.445 --> 12:35.645
like maintaining a household register.

12:35.865 --> 12:36.965
You are doing that every month.

12:37.025 --> 12:40.485
So that incentive is pretty much standard, right?

12:40.545 --> 12:41.885
Uh, even though it's against a task,

12:41.955 --> 12:43.045
it's a standard incentive

12:43.045 --> 12:44.965
that you are pro probably going to get every month.

12:45.305 --> 12:49.045
But the bulk of the payment is variable is what,

12:49.505 --> 12:51.525
is being decided month on month, right?

12:51.635 --> 12:52.885
It's, it depends on the tasks.

12:53.465 --> 12:55.645
So this is how, this is how ASHA are paid.

12:56.745 --> 13:00.365
So, so what I found was, well, first

13:00.475 --> 13:04.805
that incentives payments were very often denied to ASHA's.

13:04.805 --> 13:06.245
So even if they've done the job,

13:06.815 --> 13:10.645
there is oftentimes genuine confusion about

13:10.665 --> 13:12.125
how an incentive should be paid.

13:12.665 --> 13:14.845
Um, so I'll give you an example.

13:14.985 --> 13:18.605
An Asha who has an incentive for an antenatal checkup,

13:18.905 --> 13:20.645
you know, she's been doing antenatal visits

13:20.705 --> 13:21.925
to a pregnant woman's house,

13:22.305 --> 13:24.285
but the woman delivers a stillborn baby,

13:25.025 --> 13:27.325
and the nurse refuses to give her the incentive

13:27.345 --> 13:28.605
for the antenatal checkups

13:28.605 --> 13:31.005
because she says, what was the point of these checkups?

13:31.005 --> 13:33.485
You know, the baby was still born actually there.

13:33.605 --> 13:35.445
I mean, she's, she did the work, right?

13:35.505 --> 13:38.125
The, the incentive is actually not against the

13:38.125 --> 13:39.205
birth of a live baby.

13:39.705 --> 13:41.165
The incentive is for the checkup itself,

13:41.165 --> 13:42.245
but the nurse is confused.

13:42.745 --> 13:45.125
Uh, so the nurse just denies the incentive.

13:45.515 --> 13:47.525
What also happens sometimes is that, you know,

13:47.525 --> 13:48.525
the nurse is also confused

13:48.525 --> 13:49.885
because these incentives are shifting.

13:50.395 --> 13:52.085
Sometimes the district decides

13:52.085 --> 13:54.205
that a certain issue has been prioritized

13:54.265 --> 13:56.645
or deprioritized, so they add an incentive

13:56.665 --> 13:57.765
or they remove an incentive.

13:57.865 --> 14:00.525
So incentives, you know, they create a lot of confusion.

14:00.525 --> 14:04.045
And this confusion creates the, a denial oftentimes

14:04.185 --> 14:05.845
of payments that have been actually

14:06.105 --> 14:07.685
earned, by the as asha.

14:07.685 --> 14:08.885
So that's one finding.

14:10.125 --> 14:13.185
The other thing I found was that incentives are used

14:13.245 --> 14:16.425
by the health department as a form of leverage, as a form

14:16.425 --> 14:17.705
of control over Ashers.

14:18.095 --> 14:21.145
It's very, it becomes very easy for the health department

14:21.145 --> 14:23.745
to say, you know,

14:23.745 --> 14:26.265
we won't give you this payment till you do this other thing,

14:26.715 --> 14:27.865
which is not your work.

14:28.455 --> 14:30.265
It's beyond your brief, you know?

14:30.645 --> 14:33.065
But because you have the power to withhold this payment,

14:33.485 --> 14:36.465
you are able to take extra work from the Asher

14:36.575 --> 14:38.065
that you wouldn't be able to take if this

14:38.425 --> 14:39.585
structure wasn't there, right?

14:40.045 --> 14:42.305
So I saw this, for example, with,

14:42.485 --> 14:44.745
what's called the institutional delivery incentive.

14:45.245 --> 14:48.425
Um, ASHA have an incentive for, getting women,

14:48.535 --> 14:49.625
like I was telling you earlier,

14:50.045 --> 14:52.285
to give birth in a hospital instead of at home.

14:53.295 --> 14:54.875
Now, the state actually has two incentives.

14:55.455 --> 14:58.435
The ASHA also gets paid if a woman gives birth in a

14:58.595 --> 15:01.115
hospital, and the woman also gets paid

15:01.615 --> 15:04.195
to give birth in a public hospital instead of at home.

15:04.815 --> 15:08.435
Um, now, the district that I was working in discovered,

15:08.455 --> 15:11.995
at one point that women were not taking their,

15:12.025 --> 15:14.915
that incentive, the uptake of that incentive for the,

15:14.915 --> 15:17.915
for the pregnant women was not happening for many reasons.

15:17.975 --> 15:19.995
You know, they might not have their ID cards, you know,

15:20.215 --> 15:22.785
all kinds of, so the district decided

15:22.805 --> 15:25.305
to withhold the ASHA's incentive, you know,

15:25.305 --> 15:28.305
till the ASHA can ensure that the woman takes hers.

15:28.965 --> 15:30.505
Now, the ASHA's getting her incentive

15:30.725 --> 15:31.825
for separate work, right?

15:31.825 --> 15:33.705
For the fact that she has serviced this woman

15:33.725 --> 15:36.625
for nine months, convinced her, motivated her, brought her

15:36.625 --> 15:37.985
to the hospital,

15:38.285 --> 15:40.465
and the reason the woman's incentive is not going,

15:40.465 --> 15:42.385
could be completely outside the ASHA's control,

15:42.885 --> 15:45.705
but they decided that this was a good way of getting ASHA's

15:45.705 --> 15:48.265
to do this kind of additional uncompensated work

15:48.725 --> 15:51.625
of making sure incentives are going out to the women, right?

15:51.625 --> 15:53.745
Because they have the power to kind of, to do this.

15:53.805 --> 15:57.745
And in another, I mean, I have many examples in they've,

15:57.745 --> 16:00.145
they've tried to withhold, you know, incentive

16:00.205 --> 16:02.505
for one job to try and get Asha to do this other job.

16:02.605 --> 16:04.385
You know, that that's, that just

16:04.385 --> 16:07.225
because they can, so incentives become leverage.

16:07.225 --> 16:10.425
And this leverage also leads to, once again, you know, a,

16:10.625 --> 16:14.425
a a form of control, a form of underpayment for ASHA's.

16:14.805 --> 16:17.505
And the other thing I found was that, the,

16:17.675 --> 16:21.865
their liminal, occupational status of, of volunteer,

16:22.365 --> 16:25.425
it really erodes ASHA's legitimacy as workers.

16:26.085 --> 16:28.745
So when they're denied their payments, you know,

16:28.845 --> 16:31.985
and they try and make claims, they're very easily dismissed

16:32.005 --> 16:33.505
by health department staff, right?

16:33.505 --> 16:35.865
They get told that, I mean, so

16:35.865 --> 16:37.585
what if there's a payment delay over a few months?

16:38.125 --> 16:40.865
You know, it's not like your staff,

16:41.075 --> 16:42.625
it'll come when it'll come, right?

16:42.805 --> 16:45.305
So there's, they don't have,

16:45.455 --> 16:46.905
there's a crisis of credibility.

16:47.565 --> 16:49.745
The, the, the health depart, kind

16:49.745 --> 16:52.145
of everyday workers in the health department,

16:52.235 --> 16:55.825
don't see them as, as, as workers, you know, whose,

16:55.825 --> 16:57.185
whose pay ought to come on time

16:57.185 --> 16:59.505
and, you know, kind of ought to,

16:59.645 --> 17:01.185
not be delayed and, and all of that.

17:01.645 --> 17:05.265
In, in another instance, you know, Asha don't get a room in,

17:05.405 --> 17:08.465
in, in public hospitals where they can kind of sit and,

17:08.565 --> 17:09.625
and, and, and gather,

17:10.045 --> 17:11.305
or if they have to spend the night in

17:11.305 --> 17:12.425
the hospital, they can sleep there.

17:12.425 --> 17:13.585
They don't get a room of their own.

17:13.685 --> 17:14.705
And they complain about that.

17:14.705 --> 17:18.225
They're told, the, the person in charge

17:18.225 --> 17:21.625
of the hospital in my, district had told them,

17:21.625 --> 17:24.745
there's, there might not be room for you in the hospital,

17:25.045 --> 17:27.465
but, there's room for you in our hearts.

17:27.685 --> 17:30.305
You know, it's kind of like saying, we appreciate you,

17:30.605 --> 17:32.585
we appreciate the work that we do, that you do,

17:33.005 --> 17:36.305
but, so it, it shouldn't matter that we can't give you,

17:36.565 --> 17:38.745
a material things, you know,

17:38.745 --> 17:39.905
that we can't give you wages

17:39.905 --> 17:43.505
or we can't give you, a place to, to rest.

17:44.005 --> 17:48.785
So there's this kind of, this everyday, dismissal of

17:48.785 --> 17:51.765
Their, of their rights as workers that that is enabled

17:51.945 --> 17:54.045
by the fact that they have this liminal,

17:54.105 --> 17:55.205
occupational status.

17:55.305 --> 17:57.005
So that's, so these are the things I find,

17:57.025 --> 18:00.245
and the mechanism I find that that's obviously allowing

18:00.425 --> 18:03.885
for all of this to happen is the liminal occupational status

18:03.985 --> 18:06.765
and the way it structures their, their payment.

18:07.195 --> 18:10.325
Because incentives are being validated by nurse supervisors.

18:10.435 --> 18:13.765
This creates a mechanism of inordinate control.

18:14.305 --> 18:17.525
Um, and there are good nurses, you know, who advocate

18:17.525 --> 18:20.485
for their Ashers, but there is a problem with a system where

18:21.195 --> 18:23.685
your rights as a worker, depend

18:23.785 --> 18:27.405
so heavily on the individual proclivity of your supervisor.

18:27.615 --> 18:29.485
There is a problem with a system that does that.

18:30.235 --> 18:32.605
There's also a problem because,

18:32.935 --> 18:36.045
there is widespread contractualization in the health

18:36.045 --> 18:38.125
department today in India.

18:38.385 --> 18:41.045
So everybody who's appointed under the National Health

18:41.045 --> 18:43.245
Mission is a contractual employee,

18:43.825 --> 18:46.325
and they're not kind of permanent government employees

18:46.325 --> 18:49.445
of the, of the kind you had, you know,

18:49.505 --> 18:53.805
in in earlier cohorts, more of, so there's a normalization

18:53.825 --> 18:57.165
of pressure tactics, you know, so they don't see the problem

18:57.355 --> 18:58.845
with putting pressure on ushers

18:58.845 --> 19:02.685
because they recognize that even their own employment is,

19:02.905 --> 19:04.645
is, is exploitative.

19:05.025 --> 19:07.165
And one of them told me, for example, you know, madam,

19:07.305 --> 19:09.925
why do you, why are you so concerned about ASHA's?

19:09.925 --> 19:12.285
There's a squad hanging over everyone's necks,

19:12.625 --> 19:14.685
and the only difference is that the squad is closer

19:14.705 --> 19:16.045
to some necks than to others.

19:16.505 --> 19:21.325
You know? But this is of course, this is not the case

19:21.525 --> 19:23.165
because ahas are the only workforce

19:23.635 --> 19:26.245
that is not even considered workers that is,

19:26.305 --> 19:27.485
considered volunteers.

19:27.945 --> 19:32.125
So, so yeah, I think I find essentially that there's,

19:32.425 --> 19:34.525
the mechanism that's, that's allowing for all

19:34.525 --> 19:36.765
of this is, is the liminal occupational status,

19:36.765 --> 19:40.045
because it creates an external locus, you know,

19:40.165 --> 19:41.845
of control in the nurse supervisor.

19:42.265 --> 19:44.445
And it also normalizes control

19:44.445 --> 19:46.565
and pressure in the health department,

19:46.715 --> 19:50.685
because of, the way, labor conditions, have,

19:50.685 --> 19:53.445
have become, the recommendation would definitely be that,

19:53.715 --> 19:56.685
that you have to pay your, your,

19:57.925 --> 20:01.495
your frontline health workers a fair wage and a living wage.

20:01.795 --> 20:06.175
And, because when you don't, you rely on,

20:06.635 --> 20:08.095
the, the poor

20:08.195 --> 20:09.775
and the marginalized, you know,

20:10.195 --> 20:12.015
to subsidize your health system.

20:12.595 --> 20:16.495
And, and not only is that, is that not fair to them

20:16.495 --> 20:19.735
as workers, you know, it goes against the principles of, of,

20:19.835 --> 20:22.135
of gender justice, and it's not good

20:22.135 --> 20:23.215
for health outcomes either.

20:23.755 --> 20:25.615
Um, the conditions under which,

20:25.615 --> 20:28.055
health workers work matters very much for health outcomes.

20:28.155 --> 20:30.495
You know, we've, we've seen so much attention

20:30.755 --> 20:33.455
to essential workers to frontline health workers with covid,

20:34.155 --> 20:36.655
you know, there's so much,

20:36.845 --> 20:38.095
kind of lip service, right?

20:38.095 --> 20:40.655
Like you celebrate them as, as healthcare heroes.

20:41.115 --> 20:44.095
But here you have a, a, a very important card of,

20:44.115 --> 20:46.575
of frontline health workers in India who are

20:47.495 --> 20:48.725
Their essential workers.

20:48.795 --> 20:52.165
Were not workers, you know, so at, at, at the very minimum,

20:52.715 --> 20:55.205
they, they need to be employed,

20:55.395 --> 20:56.645
with the rights of workers.

20:57.345 --> 20:59.485
And I think as far as research is concerned,

21:00.725 --> 21:04.485
I think my research, like I was telling you,

21:04.505 --> 21:06.685
we already know from the scholarship

21:06.795 --> 21:09.525
that there is a gender wage gap, you know,

21:09.825 --> 21:12.885
and we already know that these are, these are workers

21:13.105 --> 21:15.445
who are, who have low wages.

21:16.025 --> 21:18.445
But I think my findings show you

21:18.585 --> 21:21.485
how this already low wage is further lowered.

21:22.265 --> 21:25.365
You know, it's not just that the wage is low, it is

21:25.365 --> 21:28.365
that you have a system that creates conditions

21:28.425 --> 21:31.005
for chronic underpayment and control.

21:31.285 --> 21:32.365
I think that is important.

21:32.655 --> 21:36.965
We've been paying a lot of attention to the amount in the,

21:37.305 --> 21:39.925
in the wage, you know, in the gender wage gap,

21:39.985 --> 21:42.125
how much is paid, to women.

21:42.185 --> 21:45.645
But I think it's also important now to pay attention to

21:46.385 --> 21:49.045
how the amount is paid, how the wage is structured,

21:49.115 --> 21:52.605
because I'm finding that incentives are, are

21:52.785 --> 21:56.405
as a structure problematic, you know, it not,

21:56.425 --> 21:58.925
not just in, in terms of the amount, the amount is a given

21:59.315 --> 22:00.765
that the amounts are nominal

22:00.765 --> 22:03.645
that you can know from just going through the,

22:03.825 --> 22:04.925
the figures, right?

22:05.385 --> 22:07.685
Um, so I think that, it's a,

22:07.685 --> 22:10.885
it's a new way in which the gender wage gap is

22:10.885 --> 22:12.045
being further lowered.

22:12.505 --> 22:16.125
Um, and I think it's a new way in which, the devaluation

22:16.125 --> 22:17.805
of care is being institutionalized.

22:18.425 --> 22:22.525
Um, it is what, Indian, feminist economist,

22:22.785 --> 22:26.725
PA Swami says, this is a, a formal creation of informality.

22:26.905 --> 22:29.805
The state, the public sector is where,

22:29.905 --> 22:32.725
the gender wage gap is, is increasing in India.

22:32.725 --> 22:35.045
And I think that is, really rather alarming.

"Exploring Liminality in the Context of Non-Standard Employment and Care Work Dynamics"**

00:00:00 - The concept of liminality comes from anthropology, specifically from the work of Arnold Van Op and Victor Turner. And they use liminality to describe, a state that's transitional. And that's in between, something that's been assigned by custom conventional law. So think of it this way, in its original usage, liminality describes a rite of passage in which an individual is sort of removed from a familiar group and is put through a liminal space that's characterized by uncertainty, by separation, right? And eventually the reincorporated to the group. and the second liminal stage is the stage that's kind of, it's painful.
00:00:43 - but of course it's made bearable because, you know, the individual has the support of the group, you know, it's temporary, and you also know that you're coming out on the other side, sort of from a child to an adult, right? So in its anthropological usage, liminality is, is both marginal, but it's also creative. And this concept has a very rich history. It's been used by lots of scholars and lots of, ways to describe contemporary social phenomena. It's also been critiqued it as being too kind of male-centric or to status coist or whatever. in my work, however, I'm interested in how liminality is applied
00:01:25 - So we know that over the last couple of decades, the world has seen a huge rise in what's called non-standard employment. So contract work, temporary work, gig work that departs in really fundamental ways from full-time permanent work. So the, the conversation and the scholarship is, you know, when is liminality in the world of work? When is it a good thing? When is it creative? And when is it a bad thing? When does it only create, you know, problems and more marginalizations for workers? So that's kind of, that's kind of the, the strand of scholarship that I'm interested in. And I'll give you one example of this debate in,
00:02:07 - So, for example, some scholars use the term professional hybrid to describe, people with professional backgrounds who also do managerial roles. So think about, doctors who also become hospital administrators. And the research finds actually that they're able to occupy these positions, quite well, that doctors are able to be both professionals and managers, and they're able to grow their status and grow their prestige. You know, in, in both these groups, they move between them with a lot of ease. So this literature tells you that liminality is a positive experience, but then there's further research on the experience of nurse hybrids,
00:02:49 - the same kind of power. They actually experience a lot of identity conflict when they have to move between their professional role and, and their management role. The way this conversation has advanced is to say that maybe liminality is something that powerful professions are able to use to their advantage, but, subordinated professions are not able to use to their advantage. So all this to say that the conversation on is liminality, good or bad for workers, is an ongoing one. And I think we, we kind of need more research on what it means, for all kinds of workers, right? Not just for one kind of worker. My research looks at a frontline health workforce in India.
00:03:30 - frontline health workers are a type of care worker. And scholarship already documents a wage penalty in care, alright? And the idea here is that care is, is gendered work. It's considered a social obligation, of women, really something that women are supposed to do, do naturally, you know, without boundaries in their homes and in their communities. So that is why care is devalued, considered, typically work that's worthy of good wages and good working conditions. So this is already very well documented that care work occupations carry a wage penalty. Now, a trend that you have in countries

"The Feminization of Obligation: Examining the Liminal Status of ASHA Workers in India's Health System"

00:04:12 - of gender and development are calling the feminization of obligation. So the idea is that states are appointing women to deliver public social services in roles that are quote unquote voluntary or honorary, right? And these voluntary and honorary roles, essentially what they're doing is they're not classifying these women as workers workers. So what's happening is, even though states are appointing them, states are training them, states are supervising them, states are not paying them wages, they're paying them very nominal stipends, and they're being able to sidestep labor obligations to these women workers. This is something that's been happening in India in a really big way.
00:04:50 - and more on extremely underpaid women workers to deliver, programs in health, in education, and in nutrition. So my work looks at one such workforce, that's called ASHA's or accredited social health activists. And these are about 1 million women, all women, community health workers. And we already know that there's, we already know from quantitative research that, the state has increased the gender wage gap, in the public sector, you know, through these, through employing these women workers.
00:05:32 - and that the wage gap is increasing actually in the formal sector, in India. and in fact, we know this, like I was saying to you about care work everywhere in the world. We know that care work carries a wage penalty. We also know that, non-standard work increases the gender wage gap because women are more likely than men to hold contingent jobs. So in, in quantitative terms, we already know that there is a, there is a wage gap Problem, and my research kind of, is an ethnography. So it adds a qualitative perspective to, to this, to the scholarship on the gender wage gap by asking how, how, how this, these kinds
00:06:13 - in, in frontline health work. The workforce that I, I study, ASHA's accredited social health activists, they were first appointed by the Indian State in 2005, right? And they were appointed as a part of, something called the National Rural Health Mission, which was a flagship national program, that was supposed to expand health services. And one way that it did, this is by appointing community health workers. Now, ASHA's are the community women who have about eight years of, of education. They receive, you know, a couple of weeks of training. And their job really is to connect their communities,
00:06:54 - through state health services. And, ASHA's are appointed today, across rural India and in urban India, in in informal urban settlements. So the, the way ASHA's do this is through, home visits by keeping records, doing outreach services, et cetera. And they, they do this, specifically for maternal and child health and for immunization, but also for a range of other tropical diseases and non-communicable diseases and, you know, pandemic, control, right? With Covid, for example. but at the, you know, to give you a picture of
00:07:35 - Asha are monitoring the women and children in their neighborhoods, and they're kind of making sure that, the women and children are getting the vaccinations that they're due. If, if a woman is pregnant, that she's getting the medications and the checkups that she needs, and when it's time to give birth, that she gives birth in a hospital and not at home. This is kind of, you know, chiefly what the, what the work is. But what the state has done in keeping with the feminization of obligation that I was talking about earlier, what the Indian State has done is it's, it's a, appointed us in this liminal occupational category of a paid volunteer. So Ashers are not considered workers.

The Liminal Status of ASHA Workers: Experiences of Uncompensated Labor and Systemic Control**

00:08:17 - and like I was saying, even though they are, appointed by the state and trained by the state and supervised by the state, and they put in on, most ass actually work more than 30 hours a week, right? So they're, they're doing a lot of work for the state, but the state doesn't owe them, a living wage. It only gives them stipends. And it also obviously doesn't have any other, doesn't have to give them any other kinda worker entitlements, like leave, et cetera, either, right? So, so this is, and remember I said that Asha were first appointed in 2005. So you are talking about a liminal occupational group that's pretty much at this point permanently liminal, right?
00:09:00 - not a temporary state. They're not interns. There's no career progression to, you know, becoming a permanent asra. This is it. This is just how they've been appointed and this is how they're paid. so my, my research looks at what the experience of, of liminality means for ahas in, in, in the day to day, right? And the, the way I went about my research was I, my field site is a district in, the Northwestern state, of Punjab. And the district is, called Moser. And I, I did about 12 to 14 months
00:09:43 - and then, 12 months between 2018 and 2019, most of it in a rural and urban block of Moar district. And essentially what I did was, because it was an ethnography, when I first went to Moar, I was just following Asher's, you know, following them, like I told you, as community health workers, they link their communities with the state health system. So I'm following them on both these ends. So I go with them to their communities when they do home visits, right? When they're doing, say, health camps, or they're having protests, you know, having their own meetings, all of that.
00:10:21 - when they're servicing patients in the health system, all of that. So I'm following them on both these ends. And after I do that for a couple of months, I inter I start doing interviews and I interview 60 Ashers. And the way I sample them is I interview equal numbers of rural and urban Ashers and equal numbers of Dali, which is, you know, your formerly untouchable casts for so equal numbers of Dali and dominant caste Ashers. So that's kind of how I sample. I interview 60 Ashers, and after I interview the Ashers, I also interview an additional 20, kind of ASHA program experts. So, you know, activists
00:11:01 - district level, at the state level, and at the national level. And the idea there is to kind of, you know, you have the, the ASHA point of view, and then you're able to kind of trace the consonances and dissonances between that point of view and the view of the people who, you know, are, are planning the ASHA program, and are working on the ASHA programs, the incentives that that s are, are supposed to be, paid right for their work. let me explain just very quickly how these incentives are structured, right? So the, like I was telling you, because ahas are, are not workers, they don't receive a monthly salary.
00:11:43 - and against every task is a very small incentive. So when you complete the task, you get the incentive, right? That's the idea. now The way you get the incentive is that you make a monthly report, and this monthly report, all the tasks that you list you've done in that month, they're validated, they're checked and validated by a nurse who supervises you, right? So only the tasks that the nurse validates, you know, get kind of total added up into your monthly payment. And the incentive is, is, is supposed to be kind of,

"The Complexities of Incentive Payment Structures and Their Impact on ASHA Workers"

00:12:23 - that the incentive payment structure is, has a fixed component and a variable component. It's actually kind of all variable. It's all against tasks. But there are some tasks that are very routine, like maintaining a household register. You are doing that every month. So that incentive is pretty much standard, right? even though it's against a task, it's a standard incentive that you are pro probably going to get every month. But the bulk of the payment is variable is what, is being decided month on month, right? It's, it depends on the tasks. So this is how, this is how ASHA are paid. So, so what I found was, well, first that incentives payments were very often denied to ASHA's.
00:13:06 - there is oftentimes genuine confusion about how an incentive should be paid. so I'll give you an example. An Asha who has an incentive for an antenatal checkup, you know, she's been doing antenatal visits to a pregnant woman's house, but the woman delivers a stillborn baby, and the nurse refuses to give her the incentive for the antenatal checkups because she says, what was the point of these checkups? You know, the baby was still born actually there. I mean, she's, she did the work, right? The, the incentive is actually not against the birth of a live baby. The incentive is for the checkup itself, but the nurse is confused. so the nurse just denies the incentive.
00:13:47 - the nurse is also confused because these incentives are shifting. Sometimes the district decides that a certain issue has been prioritized or deprioritized, so they add an incentive or they remove an incentive. So incentives, you know, they create a lot of confusion. And this confusion creates the, a denial oftentimes of payments that have been actually earned, by the as asha. So that's one finding. The other thing I found was that incentives are used by the health department as a form of leverage, as a form of control over Ashers. It's very, it becomes very easy for the health department to say, you know, we won't give you this payment till you do this other thing,
00:14:28 - It's beyond your brief, you know? But because you have the power to withhold this payment, you are able to take extra work from the Asher that you wouldn't be able to take if this structure wasn't there, right? So I saw this, for example, with, what's called the institutional delivery incentive. ASHA have an incentive for, getting women, like I was telling you earlier, to give birth in a hospital instead of at home. Now, the state actually has two incentives. The ASHA also gets paid if a woman gives birth in a hospital, and the woman also gets paid to give birth in a public hospital instead of at home. now, the district that I was working in discovered,
00:15:12 - that incentive, the uptake of that incentive for the, for the pregnant women was not happening for many reasons. You know, they might not have their ID cards, you know, all kinds of, so the district decided to withhold the ASHA's incentive, you know, till the ASHA can ensure that the woman takes hers. Now, the ASHA's getting her incentive for separate work, right? For the fact that she has serviced this woman for nine months, convinced her, motivated her, brought her to the hospital, and the reason the woman's incentive is not going, could be completely outside the ASHA's control, but they decided that this was a good way of getting ASHA's to do this kind of additional uncompensated work
00:15:51 - Because they have the power to kind of, to do this. And in another, I mean, I have many examples in they've, they've tried to withhold, you know, incentive for one job to try and get Asha to do this other job. You know, that that's, that just because they can, so incentives become leverage. And this leverage also leads to, once again, you know, a, a a form of control, a form of underpayment for ASHA's. And the other thing I found was that, the, their liminal, occupational status of, of volunteer, it really erodes ASHA's legitimacy as workers. So when they're denied their payments, you know,

Title: "The Crisis of Legitimacy: Examining the Liminal Status and Rights of ASHA Workers in India's Health System"

00:16:32 - by health department staff, right? They get told that, I mean, so what if there's a payment delay over a few months? You know, it's not like your staff, it'll come when it'll come, right? So there's, they don't have, there's a crisis of credibility. The, the, the health depart, kind of everyday workers in the health department, don't see them as, as, as workers, you know, whose, whose pay ought to come on time and, you know, kind of ought to, not be delayed and, and all of that. In, in another instance, you know, Asha don't get a room in, in, in public hospitals where they can kind of sit and, and, and, and gather,
00:17:11 - the hospital, they can sleep there. They don't get a room of their own. And they complain about that. They're told, the, the person in charge of the hospital in my, district had told them, there's, there might not be room for you in the hospital, but, there's room for you in our hearts. You know, it's kind of like saying, we appreciate you, we appreciate the work that we do, that you do, but, so it, it shouldn't matter that we can't give you, a material things, you know, that we can't give you wages or we can't give you, a place to, to rest. So there's this kind of, this everyday, dismissal of Their, of their rights as workers that that is enabled
00:17:54 - occupational status. So that's, so these are the things I find, and the mechanism I find that that's obviously allowing for all of this to happen is the liminal occupational status and the way it structures their, their payment. Because incentives are being validated by nurse supervisors. This creates a mechanism of inordinate control. and there are good nurses, you know, who advocate for their Ashers, but there is a problem with a system where your rights as a worker, depend so heavily on the individual proclivity of your supervisor. There is a problem with a system that does that. There's also a problem because,
00:18:36 - department today in India. So everybody who's appointed under the National Health Mission is a contractual employee, and they're not kind of permanent government employees of the, of the kind you had, you know, in in earlier cohorts, more of, so there's a normalization of pressure tactics, you know, so they don't see the problem with putting pressure on ushers because they recognize that even their own employment is, is, is exploitative. And one of them told me, for example, you know, madam, why do you, why are you so concerned about ASHA's? There's a squad hanging over everyone's necks, and the only difference is that the squad is closer
00:19:16 - You know? But this is of course, this is not the case because ahas are the only workforce that is not even considered workers that is, considered volunteers. So, so yeah, I think I find essentially that there's, the mechanism that's, that's allowing for all of this is, is the liminal occupational status, because it creates an external locus, you know, of control in the nurse supervisor. And it also normalizes control and pressure in the health department, because of, the way, labor conditions, have, have become, the recommendation would definitely be that, that you have to pay your, your,
00:20:01 - And, because when you don't, you rely on, the, the poor and the marginalized, you know, to subsidize your health system. And, and not only is that, is that not fair to them as workers, you know, it goes against the principles of, of, of gender justice, and it's not good for health outcomes either. the conditions under which, health workers work matters very much for health outcomes. You know, we've, we've seen so much attention to essential workers to frontline health workers with covid, you know, there's so much, kind of lip service, right?

"Chronic Underpayment and Institutionalized Devaluation: The Gender Wage Gap Among Frontline Health Workers in India"

00:20:41 - But here you have a, a, a very important card of, of frontline health workers in India who are Their essential workers. Were not workers, you know, so at, at, at the very minimum, they, they need to be employed, with the rights of workers. And I think as far as research is concerned, I think my research, like I was telling you, we already know from the scholarship that there is a gender wage gap, you know, and we already know that these are, these are workers who are, who have low wages. But I think my findings show you
00:21:22 - You know, it's not just that the wage is low, it is that you have a system that creates conditions for chronic underpayment and control. I think that is important. We've been paying a lot of attention to the amount in the, in the wage, you know, in the gender wage gap, how much is paid, to women. But I think it's also important now to pay attention to how the amount is paid, how the wage is structured, because I'm finding that incentives are, are as a structure problematic, you know, it not, not just in, in terms of the amount, the amount is a given
00:22:32 - that you can know from just going through the, the figures, right? so I think that, it's a, it's a new way in which the gender wage gap is being further lowered. and I think it's a new way in which, the devaluation of care is being institutionalized. it is what, Indian, feminist economist, PA Swami says, this is a, a formal creation of informality. The state, the public sector is where, the gender wage gap is, is increasing in India. And I think that is, really rather alarming.

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