In an editorial in the “Tropical Medicine and International Health” journal Ms Valery Ridde analyses how per diems have negatively impacted on health care interventions, health research and contributed to health care systems dysfunctions in Africa. She notes that “If some expect that Africa will not achieve the Millennium Development Goals by 2015, we believe per diems are contributing to that expected failure because they reduce the potential effectiveness of interventions and dilute health sector resources”.

The practice of per diems started in the end of the 1970s with the growth of development aid. The introduction of per diems was aimed at enhancing effectiveness and ensure that planned activities are prioritised and undertaken. However, this practice has been institutionalised with time and is even legislated in a number of countries. For instance the article notes that:

“in early 2010, in Mali, the United Nations agencies standardised their rates by distributing an official rate schedule for the country’s civil servants. They thereby formalised 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  for transportation costs… It thus became difficult to organise training sessions without paying the attendees, or to hold a press conference without paying the journalists.”

The author further notes that “the tyranny of per diem 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 the need to maintain one’s social status have all contributed to the generalisation of this practice”. The author further observes that per diems have especially become important for the low salaried civil servants. “Per diems have progressively become supplementary sources of income 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”.

The practice of per diems has reduced the ineffectiveness of public health interventions. This is owing to the abuses that characterise the practice. For instance, the author notes that “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 organised in a remote region because per diem rates are higher outside the capital. Civil servants will sign attendance sheets in several different workshops on the same day to obtain several per diems”.

The issue of per diems has also contributed to health care systems dysfunctions. This is owing to the fact that the players often plan their actions around the primary goal of acquiring per diems, rather than of effecting changes among the populations targeted by their intervention. The author particularly comments that “we are witnessing the notorious ‘workshop syndrome’. It can happen that bureaucrats will go through five identical training sessions. And after all that, they have learned nothing.”

The author states that these trends have a harmful effect to the health systems in Africa particularly given that per diems are a cause of low morale among civil servants who do not access them and who being demoralised  do not take part in development process. An example is given of Ghana civil servants. The author is concerned that, despite the negative effect of per diems on the health systems, the subject is seldom discussed and little research has been done in this area. It is noted that the amounts spent on per diems are very high and could instead be used in improving workers performance. An example is given of Tanzania where the budget allocated to daily allowances (per diems) for the 2008/09 fiscal year came to $390 million US.

In addition, the per diems practice has found its way into the research arena hence raising questions around research ethics and knowledge transfer. Respondents are paid to participate in research while when organising a meeting to share research findings, per diems must be paid to decision makers to participate. This trend is detrimental, especially to research ethics.

The author points out that, this problem is not limited to workers in Africa. Many expatriates, international experts and researchers from prosperous countries take advantage as well. This partly explains the silence surrounding the problem. Development partners have also not aligned themselves regarding the issue of per diems. In order to address the problem of per diems, all stakeholders must be involved. But first, there must be an acknowledgment that it is indeed a serious problem that needs to be addressed.  The author poses very important questions worth considering in addressing this problem:

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

Although there has not been research on the impact of per diems in the Kenyan health sector, anecdotal information points to the fact that the evidence presented in this editorial reflects the Kenyan situation. Therefore, these questions are important and highly relevant for Kenya government, development partners and other stakeholders in the Kenyan health sector in health systems strengthening and improving health care delivery for the Kenyan population.

Download the full article- Ridde_per diems Africa_TMIH 2010

Text by Anna Carin and Ruth Omondi