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

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