Power, Surveillance, and the Limits of Resistance

The Role of Community Health Workers in India’s Health System

Abstract

Accredited Social Health Activists (ASHAs) – a type of community health worker (CHW) in India – bridge the community with the health system, perform maternal and child health tasks, and support administrative functions. Despite their essential role, research on ASHAs and CHWs remains fragmented, often siloed into separate discussions of labor conditions, workplace hierarchies, and surveillance. As a result, the intersecting vulnerabilities faced by informal health workers like ASHAs remain underexamined. This paper addresses that gap by bridging these perspectives, with particular attention to how health systems rely on low-cost, flexible labor to sustain themselves. The analysis draws on ethnographic fieldwork in two urban sites in northern India, including participant observation with ASHAs and in-depth interviews with both ASHAs and health officials. Thematic analysis was conducted using MAXQDA. Findings reveal that ASHAs’ constrained autonomy is not simply a consequence of system inefficiencies, but a feature of governance - maintained through hierarchical task delegation, economic precarity, and ongoing surveillance. These intersecting forces limit ASHAs’ agency while allowing the health system to function without structural reform. Without recognizing how power operates across all levels of the health system, research and policy risk perpetuating a cycle that fails to address the foundations of inequity in the name of public health. While grounded in the Indian context, this analysis offers conceptual tools for examining how informal health labor is governed and constrained across health systems in low- and middle-income countries.