Beyond Core Duties: A Framework for Reimagining Community Health Worker Contributions to Health Systems

Community Health Workers (CHWs) are essential to global health systems, yet existing research predominately focuses on their core responsibilities, such as maternal and child health, without accounting for the full scope of their labor. This study examines the overlooked dimensions of CHW work through an ethnographic case study of Accredited Social Health Activists (ASHAs) in urban India. Drawing on three months of participant observation and 25 in-depth interviews with ASHAs and health system stakeholders across two sites in Punjab, we identified three interrelated workstreams that define ASHA labor: core duties, secondary responsibilities, and supplementary engagements. Core duties are formally mandated health services implemented through health-related offices. Secondary responsibilities - such as election duties - are often imposed on ASHAs by the health system, but are driven by priorities of non-health ministries. Supplementary engagements involve paid or unpaid work with non-governmental organizations and private actors. Together, these workstreams reveal the extent to which ASHAs are relied upon to fill systemic gaps in under-resourced public systems. These crucial overlapping roles frequently stretch ASHAs beyond their capacity, affecting their ability to deliver on core maternal and child health responsibilities and exposing them to exploitative or informal labor arrangements. Our findings underscore the inadequacy of current frameworks that fail to capture the full complexity of CHW roles. We propose a new conceptual framework to analyze CHW labor holistically, grounded in their personal experiences and the institutional constraints that they face. This framework lays the groundwork for rethinking CHW labor across global contexts, guiding research, policy, and practice aimed at ensuring fair compensation, clearer role delineation, and stronger systemic support for CHWs and for more equitable health systems.