SEARCH

SEARCH BY CITATION

Keywords:

  • perdiems;
  • incentives;
  • research;
  • Africa;
  • aid

Acute ‘perdiemitis’ is decidedly one of the most prevalent illnesses in African public health projects. When a novice (African or Westerner) first undertakes a research project or implements a public health intervention, he will encounter the diplomatically phrased question: ‘What are the administrative modalities?’ These days, anyone attending a research results presentation workshop, a training session, or an intervention expects that the organizers will pay him a premium – a per diem – for his participation. While per diems appear to have been originally used to compensate for the loss of time and income caused by such participation, today they have become political instruments that taint research and intervention activities. If some expect that Africa will not achieve the Millennium Development Goals by 2015 (Murray et al. 2007), we believe per diems are contributing to that expected failure (without, of course, explaining it entirely), because they reduce the potential effectiveness of interventions and dilute health sector resources. While this commentary is focused on the health sector, it should be clearly noted that the issue of per diems also affects other areas such as housing construction (Bähre 2005), economic development (Phonphakdee et al. 2009) and water supply (Bradley & Karunadasa 1989). The aim of this commentary is not to throw stones at anyone in particular. Rather, it is to bring to light this phenomenon, known to all but seldom mentioned and little studied (Vian 2009), to suggest a deliberative process (Culyer & Lomas 2006) to find an equitable treatment for this long-neglected disease.

The arrival of per diems and the reasons behind them

  1. Top of page
  2. The arrival of per diems and the reasons behind them
  3. Reducing the effectiveness of public health interventions
  4. Contributing to healthcare systems dysfunction
  5. Questions around research ethics and knowledge transfer
  6. Finding a solution together
  7. Acknowledgements
  8. References

While the history of per diems remains to be written, it appears these practices arose at the end of the 1970s with the growth of development aid. Up to then, health workers carried out their activities and were remunerated with their salaries and no other payments except for travel costs. They were often hosted in remote regions by their colleagues or by villagers, who housed and fed them. Then, the massive arrival of the development industry gave rise to new funding modalities. In these development projects, very well-paid expatriate aid workers carried out activities with their African colleagues who were much less well paid. Thus, the aid workers introduced these per diems, perhaps out of ethical concerns, but mainly motivated by a desire for effectiveness, to ensure these activities would take place. As the years went by, habits were formed, and the practice was institutionalized; even the Financial Times called it ‘the culture of the ‘per diem’’ (Jack 2009). Today, it has practically become a right, and some States (e.g. Niger, Mali, Burkina Faso) even legislate on the subject.

For example, in 2007 in Burkina Faso, five presidential decrees dealt with project functioning and the standardization of per diem rates. The hierarchy of per diems was established, with drivers receiving less than project coordinators, even though they might be assumed to have the same needs for food and lodging. However, donor agencies were not willing to ‘align’ themselves (to use the Paris Declaration terminology) with these amounts; nor were they able to agree on an alternative. In early 2010, in Mali, the United Nations agencies standardized their rates by distributing an official rate schedule for the country’s civil servants. They thereby formalized the fact, for instance, that someone attending a training session in the capital, his city of residence, must receive an amount equivalent to $10 US (5000 F CFA) for transportation costs. Article four of Decree 779 in Burkina Faso, in 2007, ratified exactly the same principles and the same amount. It thus became difficult to organize training sessions without paying the attendees, or to hold a press conference without paying the journalists.

‘The tyranny of per diem’ (Jack 2009) has made it impossible to do much of anything without these payments. The competition among projects, public servants’ low salaries in the face of an ever-growing cost of living (and for some, the desire for display) and the need to maintain one’s social status have all contributed to the generalization of this practice. Jaffré (2003), like Dujardin (2003), thus explains that in West Africa, health workers’ inadequate salaries do not allow them to undertake inter-community communication ‘upon which mutual support among families or ‘colleagues’ is based.’ Structural adjustment programs, the demands of maintaining and even reducing salary costs (Chêne 2009) and the weakening of the role of the States in Africa (Olivier de Sardan 2000) have led to a situation in which these per diems have become essential for civil servants. Per diems have progressively become supplementary sources of income (Muula & Maseko 2006; McCoy et al. 2008) that are never taxed. One study in two districts of Burkina Faso showed that health workers’ median annual income from per diems exceeded their salaries ($1900 vs. $1500 US) (Ensor et al. 2006).

Reducing the effectiveness of public health interventions

  1. Top of page
  2. The arrival of per diems and the reasons behind them
  3. Reducing the effectiveness of public health interventions
  4. Contributing to healthcare systems dysfunction
  5. Questions around research ethics and knowledge transfer
  6. Finding a solution together
  7. Acknowledgements
  8. References

Fifteen years of observations allow me to bring to light certain abuses. Some project leaders will offer higher daily rates than a competing project to be sure they will have more public servants at their training sessions. Sometimes a workshop will be organized in a remote region because per diem rates are higher outside the capital (Vian 2009). Civil servants will sign attendance sheets in several different workshops on the same day to obtain several per diems. This has been called the ‘leapfrog’ strategy (Muula & Maseko 2006), or ‘hunting and gathering’ (Swidler & Watkins 2009). Some officials will sign for a colleague to obtain and share the income. One person with whom I discussed this practice called per diems ‘legalized corruption’. Per diems’ corruptive role was well explained in a study carried out in a neighbourhood of Cape Town in South Africa (Bähre 2005). The use of per diems could thus be seen as a form of corruption (Chêne 2009) that helps to make sense of, among other things, ‘the entire functioning (or rather, dysfunctioning) of the State’ (Blundo & Olivier de Sardan 2000).

It is also well understood that the per diem problem is not confined to Africans or Asians (Chêne 2009). Many expatriates, international experts and researchers from prosperous countries blithely take advantage as well, which partly explains the negotiated order (Strauss 1978) and the total absence of debate on per diems. This order is a construct that is social, negotiated and temporal, within a context of interactions between the societal actors that, for the time being, favours the status quo. The per diem rate for travel greatly exceeds the cost of living in the countries these workers visit, even when, for the sake of representation, they require more commodious lodging. But, as was explained to me by someone criticized by his colleagues for organizing more overseas missions than necessary and for living in precarious conditions on these missions, ‘this allows me to save some money’. These examples could be endlessly multiplied, although it is important to point out that not all actors adopt these practices. Fortunately, there are still some researchers, nurses and senior officials who do not play this game.

Contributing to healthcare systems dysfunction

  1. Top of page
  2. The arrival of per diems and the reasons behind them
  3. Reducing the effectiveness of public health interventions
  4. Contributing to healthcare systems dysfunction
  5. Questions around research ethics and knowledge transfer
  6. Finding a solution together
  7. Acknowledgements
  8. References

Very often, these practices have dramatic impacts on the healthcare system. The players plan their actions around the primary goal of acquiring per diems, rather than of effecting changes among the publics targeted by their intervention. We are witnessing the notorious ‘workshop syndrome’ (Foster 1987), dubbed ‘trainingism’ in the 1970s (Schaffer 1974). ‘It can happen that bureaucrats will go through five identical training sessions. And after all that, they have learned nothing.’ (Hakizimana 2007). While health workers reap the benefit of per diems, the general population is not blind. People are fully aware of this way of operating, even as health policies stress the importance of their volunteering to serve on health centres’ management committees. Comparing these health workers’ salaries to the incomes of the rural population, we are justified in considering these practices unethical on the part of those who have sworn to serve the State and to respect the Hippocratic oath. Some health workers have even coined a vulgar expression for when the rate provided is too low: a ‘merdiem’ (‘crap diem’). Health workers will rarely go out to vaccinate children if they do not ‘get something in return’, such as on National Vaccination Days.

The impact of the per diem practice described in our article, as well as in other studies in Mozambique (Pfeiffer 2003), Nigeria (Smith 2003), Mali (Berche 1998) and Burkina Faso (Nguyen 2002; Ridde 2008), is deleterious to the organization of health systems in Africa. For example, Jacquemot (2007), considers that per diems are the cause of poor morale among civil servants in Ghana who do not have access to them and who, being thus disillusioned, do not take part in development processes. Yet there are very few studies on per diems, and we know little about the underground economy and the financial contribution of such practices to the healthcare system. This subject is off-limits, and researchers would rather study performance-based bonuses than raise the sensitive question of per diems. Certainly, the amount spent on per diems at the level of an entire country could be applied to improving workers’ performance. For example, in Tanzania, the budget allocated to daily allowances (per diems) for the 2008/09 fiscal year came to $390 million US (Chêne 2009).

Questions around research ethics and knowledge transfer

  1. Top of page
  2. The arrival of per diems and the reasons behind them
  3. Reducing the effectiveness of public health interventions
  4. Contributing to healthcare systems dysfunction
  5. Questions around research ethics and knowledge transfer
  6. Finding a solution together
  7. Acknowledgements
  8. References

These per diem practices that have been around for a long time and that corrupt public health interventions are finding their way into research ethics. A woman is given ‘soap money’ as a reward for completing a questionnaire on maternal mortality. The village residents are not fools; they are perfectly aware of the salaries of the surveyors who come to question them, while they rarely see the results of the studies and their living conditions do not change. Some ethics committees in Africa now demand per diems to analyse the ethical qualities of research protocols. These days, when we organize a meeting to share the results of a study that are useful for action, which is now part of the researchers’ responsibility (Ridde 2009), we must pay per diems to decision-makers to ensure their attendance. The practice of paying per diems in research is also detrimental; it is therefore important to pay attention to their consequences to ensure our research practices are ethical (Nuffield Council on Bioethics 2005).

Finding a solution together

  1. Top of page
  2. The arrival of per diems and the reasons behind them
  3. Reducing the effectiveness of public health interventions
  4. Contributing to healthcare systems dysfunction
  5. Questions around research ethics and knowledge transfer
  6. Finding a solution together
  7. Acknowledgements
  8. References

Obviously, there are no simple solutions to such a complex problem. Ideas for solutions can only emerge if there is a public and participative process involving all stakeholders, because even the donor agencies are not aligned on this subject, contrary to the Paris Declaration. Given the stakes, quick decisions will not work. Everyone has buried their head in the sand. Who will dare to bring this phenomenon out into the open? To find a solution for any given problem requires that it be acknowledged, first, as a public problem (Rochefort & Cobb 1994). Yet, for the time being, the question of per diems does not figure at any discussion table in the international arena of research and development projects. At some point, we will need to consider how to address this problem. Should we

  • • 
    ask the donor agencies to convert per diem budgets to financial support for improving salaries and working conditions?
  • • 
    legislate the rates for per diems to harmonize practices and make the system transparent?
  • • 
    pay per diems in accordance with needs rather than administrative hierarchies?
  • • 
    insist on more effective governance models?
  • • 
    review the salaries of staff in High Income Countries institutions to make them more reasonable?

All of these are questions that are worth presenting dispassionately to the development community for serious consideration.

Acknowledgements

  1. Top of page
  2. The arrival of per diems and the reasons behind them
  3. Reducing the effectiveness of public health interventions
  4. Contributing to healthcare systems dysfunction
  5. Questions around research ethics and knowledge transfer
  6. Finding a solution together
  7. Acknowledgements
  8. References

V. Ridde is a Canadian Institutes for Health Research (CIHR) New Investigator. Thanks to Emilie Robert for literature search and Donna Riley for translation and editing support.

References

  1. Top of page
  2. The arrival of per diems and the reasons behind them
  3. Reducing the effectiveness of public health interventions
  4. Contributing to healthcare systems dysfunction
  5. Questions around research ethics and knowledge transfer
  6. Finding a solution together
  7. Acknowledgements
  8. References
  • Bähre E (2005) How to ignore corruption: reporting the shortcomings of development in South Africa. Current Anthropology 46, 107120.
  • Berche T (1998). Anthropologie et santé publique en pays dogon. APAD-Karthala, Paris.
  • Blundo G & Olivier de Sardan J-P (2000) La corruption comme terrain. Pour une approche socio-anthropologique. In: Monnayer les pouvoirs. Espaces, mécanismes et représentation de la corruption (ed. GBlundo) IUED, Geneva-Paris, pp. 2146.
  • Bradley RM & Karunadasa HI (1989) Community participation in the water supply sector in Sri Lanka. The Journal of the Royal Society for the Promotion of Health 109, 131136.
  • Chêne M (2009). Low salaries, the culture of per diems and corruption. U4 Expert answer. Transparency International. http://www.u4.no/helpdesk/helpdesk/query.cfm?id=220 (accessed on 9 June 2010).
  • Culyer AJ & Lomas J (2006) Deliberative processes and evidence-informed decision-making in healthcare: do they work and how we might know? Evidence and Policy, 2, 357371.
  • Dujardin B (2003) Politiques de santé et attentes des patients. Vers un nouveau dialogue. Editions Charles Léopold Mayer, Paris, Karthala.
  • Ensor T, Chapman G & Barro M (2006) Paying and Motivating CSPS Staff in Burkina Faso: Evidence From Two Districts. Policy and Health Systems, Impact, Aberdeen & Burkina Faso.
  • Foster GM (1987) Bureaucratic aspects of international health agencies. Social Science & Medicine 25, 10391048.
  • Hakizimana A (2007) La course au per diem, un sport national ruineux. Madagascar Tribune November 17.
  • Jack A (2009) Expenses culture has high cost for world’s poorest nations. The Financial Times July 29.
  • Jacquemot P (2007) Harmonisation et appropriation de l’aide: commentaires autour de l’experience du Ghana. Afrique Contemporaine 3–4, 161191.
  • Jaffré Y (2003) Chapitre 5. Le rapport à l’autre dans des services sanitaires d’Afrique de l’Ouest (Bamako, Dakar, Niamey). Journal International de Bioéthique 2003/1–2. 14, 101119.
  • McCoy D, Bennett S, Witter S et al. (2008) Salaries and incomes of health workers in sub-Saharan Africa. The Lancet – British Edition 371, 675681.
  • Murray CJ, Laakso T, Shibuya K, Hill K & Lopez AD (2007) Can we achieve Millennium Development Goal 4? New analysis of country trends and forecasts of under-5 mortality to 2015. Lancet 370, 10401054.
  • Muula A & Maseko F (2006) How are health professionals earning their living in Malawi? BMC Health Services Research 6, 97.
  • Nguyen V-K (2002) Sida, ONG et la politique du témoignage en Afrique de l’Ouest. Anthropologie et Sociétés 26, 6987.
  • Nuffield Council on Bioethics (2005) The ethics of research related to healthcare in developing countries: a follow-up Discussion Paper based on the Workshop held in Cape Town, South Africa 12–14th February 2004. Nuffield Council on Bioethics, London.
  • Olivier de Sardan J-P (2000) Dramatique déliquescence des États en Afrique. Le Monde Diplomatique février 2000, 1213.
  • Pfeiffer J (2003) International NGOs and primary health care in Mozambique : the need for a new model of collaboration. Social Science & Medicine 56, 725738.
  • Phonphakdee S, Visal S & Sauter G (2009) The Urban Poor Development Fund in Cambodia: supporting local and citywide development. Environment and Urbanization 21, 569586.
  • Ridde V (2008) “The problem of the worst-off is dealt with after all other issues”: the equity and health policy implementation gap in Burkina Faso. Social Science & Medicine 66, 13681378.
  • Ridde V (2009) Knowledge transfer and the university system’s functioning: need for change. Global Health Promotion 16, 35.
  • Rochefort DA & Cobb RW (1994) Problem definition: an emerging perspective. In: The Politics of Problem Definition. Shaping the Policy Agenda (eds DARochefort & RWCobb) University Press of Kansas, Lawrence, Kansas, pp. 131.
  • Schaffer BB (1974) Introduction: the ideas and institutions of training. In: Administrative Training and Development. A Comparative Study of East Africa, Zambia, Pakistan, and India (ed. BSchaffer) Praeger, New York.
  • Smith DJ (2003) Patronage, per diems and the “Workshop mentality”: the practice of family planning programs in Southeastern Nigeria. World Development 31, 703715.
  • Strauss AL (1978) Negotiations: Varieties, Contexts, Processes, and Social Order Jossey-Bass, San Francisco.
  • Swidler A & Watkins SC (2009) “Teach a man to fish”: the sustainability doctrine and its social consequences. World Development 37, 11821196.
  • Vian T (2009) Benefits and drawbacks of per diems: do allowances distort good governance in the health sector. CMI CHR Michelsen Institute, Bergen, Norway, Anti-corruption resource centre. http://www.cmi.no/publications/file/3523-benefits-and-drawbacks-of-per-diems.pdf (accessed on 9 June 2010).