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Paper long abstract

There are persistent health inequities in Global South that are shaped by asymmetrical power structures in health financing, governance, and implementation. This paper examines maternal health governance in India through the lens of community agency, focusing on the role of Accredited Social Health Activist as an intermediary between state policy and lived realities. Reduction of the Maternal Mortality Ratio is a core commitment under the United Nations SDGs, yet India underperforms relative to global targets, with subnational disparities. Madhya Pradesh illustrates how structural poverty, gendered inequalities, and uneven public health financing constrain maternal health outcomes.

The analysis is grounded in the reproductive justice framework, which situates maternal health within intersecting structures of gender, caste, class, and state power, moving beyond biomedical or rights-based approaches. It also draws on James C. Scott’s concept of everyday forms of resistance to examine how ASHAs negotiate policy mandates through informal practices, selective compliance, and community mediation. These negotiations generate differential policy outcomes and unviels the limits of top-down health governance.

Methodologically, the study adopts a qualitative design based on a case study of two districts in Madhya Pradesh, Rewa and Agar Malwa, identified respectively as lower- and higher-performing districts using indicators from the National Family Health Survey- 5. Primary insights derive from focus group discussions with 150 ASHAs and are triangulated with secondary sources, including government reports, programme guidelines, national datasets, and scholarly literature. The paper argues that MMR reduction requires maternal health governance that recognises and strengthens community agency rather than instrumentalising it.