Paper short abstract:

This paper describes a comparative ethnography of 8 districts across Sub-Saharan Africa and South Asia tracing the effects of global health policy on local health systems. This paper explores the health systems effects of per diems provided by the Global Polio Eradication Initiative.

Paper long abstract:

In 2012, a group of anthropologists, sociologists, and health systems researchers carried out a comparative ethnography of the impact of the Global Polio Eradication Initiative on health systems. We conducted research at 8 research sites in 7 countries (Nepal, India, Pakistan, Ethiopia, Nigeria, Rwanda, and Angola). At each site, we conducted a thorough document review; about 40 interviews with district level officials, ground level workers, and those served by the health system; and participant observation in the activities of the health system, with a particular focus on immunization. Our goal was to create a systematically comparable, ethnographically rich analysis of the effects of global policy on health systems.

This paper focuses on a phenomenon that emerged as salient in nearly all of our case studies, the impacts of per diems. The Global Polio Eradication Initiative provides low per diems (around $1-$2 per day in most places) to ground-level health staff like Community Health Workers for their work on polio campaigns. Across our case studies, these per diems had largely negative effects on worker motivation and performance. They were sufficient to ensure that workers focused on polio eradication rather than other tasks; but because they were so low and frequently arrived late, they were the common subject of bitter complaints. The very low rate of pay per diems represented was in many cases experienced by workers as a slight. Comparative ethnography has the power to illuminate when and how low per diems were especially damaging, and to provide possible ways forward.