An open and frank discussion about the extent and impact of per diems on the functioning of health interventions, systems and research is important. While the 'culture of per diems’ can be associated with civil servants involved in health care projects and delivery, we suggest that a more balanced argument would be presented, if per diems were discussed in relation to macroeconomic and structural influences.This does not preclude examination in an African context but it is a reminder that this issue is not inherently African. All actors in global health should be named and examined accordingly.