Per diems undermine health interventions, systems and research in Africa: burying our heads in the sand.

keywords: perdiems, incentives, research, Africa, aidAcute ‘perdiemitis’ is decidedly one of the most prevalentillnesses in African public health projects. When a novice(African or Westerner) ﬁrst undertakes a research projector implements a public health intervention, he willencounter the diplomatically phrased question: ‘Whatare the administrative modalities? ’ These days, anyoneattending a research results presentation workshop, atraining session, or an intervention expects that theorganizers will pay him a premium – a per diem – for hisparticipation. While per diems appear to have beenoriginally used to compensate for the loss of time andincome caused by such participation, today they havebecome political instruments that taint research andintervention activities. If some expect that Africa will notachieve the Millennium Development Goals by 2015(Murray et al. 2007), we believe per diems are contributingto that expected failure (without, of course, explaining itentirely), because they reduce the potential effectiveness ofinterventions and dilute health sector resources. While thiscommentary is focused on the health sector, it should beclearly noted that the issue of per diems also affects otherareas such as housing construction (Ba¨hre 2005), economicdevelopment (Phonphakdee et al. 2009) and water supply(Bradley & Karunadasa 1989). The aim of this commen-tary is not to throw stones at anyone in particular. Rather,it is to bring to light this phenomenon, known to all butseldom mentioned and little studied (Vian 2009), to suggesta deliberative process (Culyer & Lomas 2006) to ﬁnd anequitable treatment for this long-neglected disease.The arrival of per diems and the reasons behind themWhile the history of per diems remains to be written, itappears these practices arose at the end of the 1970s withthe growth of development aid. Up to then, healthworkers carried out their activities and were remuneratedwith their salaries and no other payments except fortravel costs. They were often hosted in remote regions bytheir colleagues or by villagers, who housed and fed them.Then, the massive arrival of the development industrygave rise to new funding modalities. In these developmentprojects, very well-paid expatriate aid workers carried outactivities with their African colleagues who were muchless well paid. Thus, the aid workers introduced these perdiems, perhaps out of ethical concerns, but mainlymotivated by a desire for effectiveness, to ensure theseactivities would take place. As the years went by, habitswere formed, and the practice was institutionalized; eventhe Financial Times called it ‘the culture of the ‘per diem’’(Jack 2009). Today, it has practically become a right, andsome States (e.g. Niger, Mali, Burkina Faso) even legislateon the subject.For example, in 2007 in Burkina Faso, ﬁve presidentialdecrees dealt with project functioning and the standardi-zation of per diem rates. The hierarchy of per diems wasestablished, with drivers receiving less than project coor-dinators, even though they might be assumed to have thesame needs for food and lodging. However, donor agencieswere not willing to ‘align’ themselves (to use the ParisDeclaration terminology) with these amounts; nor werethey able to agree on an alternative. In early 2010, in Mali,the United Nations agencies standardized their rates bydistributing an ofﬁcial rate schedule for the country’s civilservants. They thereby formalized the fact, for instance,that someone attending a training session in the capital, hiscity of residence, must receive an amount equivalent to $10US (5000 F CFA) for transportation costs. Article four ofDecree 779 in Burkina Faso, in 2007, ratiﬁed exactly thesame principles and the same amount. It thus becamedifﬁcult to organize training sessions without paying theattendees, or to hold a press conference without paying thejournalists.