Re-centering Morality in International Development

Written by
Ishita Batra
April 28, 2022

by Ishita Batra, MPA '23 for Annotations Blog

Professor Manish Bhardwaj is the CEO and co-founder of Innovators In Health, a non-profit that works to ensure the rural poor in India have access to quality healthcare. He is also a Visiting Lecturer and was the 2021-22 James Wei Visiting Professor in Entrepreneurship at the Keller Center at Princeton University. 

In this interview, he discusses the role of moral clarity and accountability in development. He also explains how to reframe development as a social justice project in which the highest quality of care is provided to those who need it most.

This interview has been edited for length and clarity. 

Headshot of Manish Bhardwaj

What is the role of moral clarity in development projects? 

My project is that we should stop framing everything in instrumental, metric-driven terms. If you do an international development project, you will always hear these things like it should be replicable, scalable, cost-effective, etc. My project is to move away from that very instrumental framing and remind ourselves that these are problems of justice. It's about right and wrong. You can call it a moral framing, or moral clarity.

What does it mean to reframe problems with a moral framing? 

One way is to first talk about the ends - where do we want to go - and to understand those properly. As an example – when you encounter someone in rural healthcare, what is your obligation to this person? You don't answer that question by looking at the resources you have or what you're doing. You try to answer that question in a way that you are unconstrained by what you are able to do. It's what you ought to do. Those are the ends. 

And these ends have to be permissible. What you should do should be rational, reasonable, and decided by consultation. It should be what you would do for yourself, or for someone who is very dear to you. What you should do is affirm someone's humanity. 

Then there are means, permissible means. You can rob a bank and run a tuberculosis treatment program and everyone will agree that is wrong. It's not just about what results you have. “Permissible means” means that you have to pursue just ends in a just way. For instance, how you pursue your ends must be broadly consultative. The organization must be internally just and aware of its own prejudices and the demands it makes of its employees. The organization also should not undermine public systems, etc.

To understand this more practically - how does this worldview relate to your organization's mission and how you operate?

For instance, the permissible end is that there should not be two standards of care. There's a lot more, but very simply, we should not have different standards of care – one standard for someone who is wealthy, and a lower standard for someone who is not. 

In terms of permissible means in healthcare: you cannot execute the programs without the community having a significant say in its goals and how it's executed. We will consult very widely, and what we should ideally have is the community having the power to change key decisions. 

Another aspect of permissible means is how you treat people within the organization. Where we operate, you'll see a lot of misogyny, religious intolerance, casteism. You have to actively fight these scourges. 

As the liberation theologists say, the poor are not instruments of our ambition. This is what we have to understand. You have to earn the right to serve.

What is the role of accompaniment in the work you do? 

You literally walk with your patients through their journey and you don't leave their side in their cure. This is for global health, but it's a much broader concept - you journey with the wronged until right is done. The concept of accompaniment is very old. It originates in liberation theology, and I was very influenced by Partners in Health and Paul Farmer in particular. 

What it means practically is that you don't have a 3-point intervention or an app or a gadget. You say: my goal is to cure someone, and then you try and solve every particular problem for this person in a particular place. 

In our maternal and neonatal health program, we just want to get someone to the delivery room in time. Sometimes a road gets flooded; other times, you're trying to convince a family; a third time, the labor nurse won't treat a lower caste woman. The problems keep changing, but it's about being present as much as possible and physically being with the person you're trying to help. 

That's a very powerful way to affirm someone. You don't accompany out of pity or in a position of power. Properly done, you have to accompany as an equal. What that means is to humanize the other person. It's not just that they are a patient with a problem. When you journey with the person, you're also learning who they are and understanding them. And they participate in what should be done. They're not sitting ducks for you to deliver service.

ASHA worker (female community healthcare worker) Sangeeta Devi giving TB drugs to a pediatric patient Rajeev Kumar.

An ASHA worker (female community healthcare worker) Sangeeta Devi gives TB drugs to a pediatric patient Rajeev Kumar. Credit: Innovators in Health.

How do you reconcile your commitment to accompaniment and high standards of care with budget and resource constraints? 

First, when you're deciding what care someone should get, don't look at the budget. There are the things we ought to do for patients – and it's very easy to identify them. Just think of what care you would want those dear to you to receive – and that’s the list of things you need to do. And if we do less than that, then we aren't doing enough. 

You'll have some constraints, then you look at the list and see what is it you can do. And if you're shrinking that list, then you have to be honest with everyone: your patients, your staff, your donors. You say, “I know we are asking you to travel and we wish that we could have covered the cost of transport and lost wages. But we are not able to do it.” It's a way of making yourself accountable. 

What is the most common disagreement people have with your worldview and the way your organization works? 

The insistence that it is more important to be morally exemplary than to scale goes against a lot of the prevailing thinking in international development.

We are not ideologues about any of this. The point is that you should not compromise the ideal treatment just because you are not able to do it today. Because that shifts the goalposts. When you shift that goalpost, what is the incentive to try harder to improve that standard of care? 

You can say: “If you want to fix tuberculosis, you have to be cost-effective. You have to come under (say) a hundred dollars per patient treated.” At that point, you have shrunk the list of things you should be doing. Instead of saying “This is what we can do, and it’s not the same as what we should do”, you're justifying the shrunk list. In fact, the shrunk list is almost seen like the better thing to do. You're a better organization because you can still cure 95% of people with a shrunk list, even though the 5% that you miss out are generally the ones who need the help the most. 

In the case of Innovators in Health, we provide high quality medical treatment to patients with tuberculosis. But there's also a huge nutritional component and psychological support which we are unable to provide. You could wash your hands of it. I think our patients would still have been grateful that we were getting them medicine. But we kept insisting to the community, our staff, our donors, and everyone else: it’s not right that we are not providing food. We’re giving our patients four antibiotics a day, and they are clearly undernourished. 

So, we found a way to provide some nutrition through milk cooperatives. It is nowhere near what is necessary, but it is some nutrition and it is provided at no cost to us. 

So yes, I think the biggest disagreement would be the deep utilitarian foundation of international development. We aren’t saying no to compromise. What we are saying is, don't normalize your compromise. 

Can you talk a bit more about your program’s focus on community involvement and accountability? 

There is a conceit in international development that we can show up anywhere in the world and work with very disadvantaged communities without adequately being controlled by them. No one's elected me. No one called me to work on tuberculosis, but I'm able to go and start this. I don't think we have done harm, but I would like to see more of that realization - and even that will induce some humility and likely reduce harm. 

What we would really like to see is community members being able to sit on the board and actually control stuff. It's not about changing the world. I do not like that framing. I use it sometimes; it's a well-meaning phrase. But, as the liberation theologists say, the poor are not instruments of our ambition. This is what we have to understand. You have to earn the right to serve. So before you start, you need to have these extensive conversations and develop a connection and a deep commitment to a particular place.

Headshot of Ishita Batra, MPA 23
Meet the Author: Ishita Batra

Ishita Batra is an MPA '23 student at Princeton University's School of Public and International Affairs. 

Prior to coming to Princeton, Ishita was a Senior Associate at the nonprofit IDinsight in New Delhi. In this role, she worked with government and nonprofit partners to improve financial inclusion outcomes, and developed a free resource that guides nonprofits on how to use evidence. She has also previously worked in economic consulting in Washington, D.C.

Ishita is from New Delhi, and holds an undergraduate degree in Economics from the University of Pennsylvania.