Power, surveillance, and the limits of resistance: The role of community health workers in India's health system

Accredited Social Health Activist (ASHA) workers, India's community health workers (CHWs), serve as the primary link between households and the health system. They perform essential maternal and child health tasks while absorbing administrative and programmatic responsibilities. However, research on ASHAs and CHWs remains fragmented, often siloed into separate discussions of labor conditions, workplace hierarchies, and surveillance. This paper integrates these perspectives to examine how health systems rely on low-cost, flexible labor to sustain themselves. Drawing on ethnographic fieldwork in India, including participant observation and in-depth interviews, this analysis shows that ASHAs' constrained autonomy is not only the result of systemic inefficiencies, but is shaped by governance arrangements that produce and reinforce disempowerment. Findings reveal that hierarchical task delegation, economic precarity, and routine surveillance work in tandem to constrain autonomy among ASHAs. These conditions limit their capacity to resist expanding responsibilities, while simultaneously enabling the health system to function without structural reform. This analysis offers conceptual tools for understanding how informal health labor is governed, disciplined, and constrained across CHW programs in low- and middle-income countries.