Reproducing the state : women community health volunteers in north India

India’s community health worker program is the largest in the world. Its one-million strong, all-women workforce is a success story. Since their appointment in 2005, these women, called ASHAs (Accredited Social Health Activists), have spearheaded significant improvements in the country’s maternal and child health outcomes. However, ASHAs are an exceptionally precarious workforce. They are “paid volunteers”, who receive none of the benefits of staff, and get per-case “incentives” instead of salaries. These poor and mostly lower caste women work round-the-clock in an under-resourced and over-burdened health system, for an itinerant pay that is a fraction of minimum wage. Given these conditions, I ask, how do ASHAs succeed in delivering health services? And what does their success tell us about state power? I conducted 14 months of ethnographic fieldwork in North India, mostly in Punjab, including 80 interviews with ASHAs and ASHA program experts. I find that ASHAs reveal the productive power of an under-studied and gendered role in the state, that of a frontline bureaucrat. Frontline bureaucrats expand the reach of the state into communities. Although the gender, caste, and class marginality of ASHAs subsidizes the Indian state’s health system, ASHAs craft themselves into highly sought-after actors in service delivery. They do so by cultivating deeply intimate knowledge of women clients and their families, and by building networks among both public and private health care providers. In this way, they get not just intrinsic rewards—like skills, emotional fulfilment etc. usually associated with care work—but also extrinsic rewards, like commissions earned by referring patients to private clinics. I also find the care work of ASHAs comprises political socialization, that is, ASHAs educate their communities about the workings of the state, particularly welfare schemes, thus maintaining state legitimacy from below. In effect then, the very marginality that traps ASHAs into care work also unexpectedly allows them to maneuver into a social location of relative power within their communities.