German Development Cooperation in Malawi

1. German Development Cooperation in Malawi Evaluation on the Outcome of HIV Mainstreaming Activities in Malawi 2010 Alick Kafunda (GTZ) and Marion Koerbel (DED) Dr. Samuel Wafo Nairobi, 09.06.2010

2. Malawi German Health Sector Program Human resource problem  in alignment with the National AIDS Framework • Care of the Carer policy and HIV and AIDS Workplace policy (2005) HIV/AIDS Mainstreaming:  strategy was build for the 5 different Zones in Malawi  Implementation started in 2 Zones: Selected for HIV MS EV

3. Background: Malawi-German Cooperation in the Health Sector • German Development Cooperation supports the program of work of the health Sector Wide Approach (SWAp):  HIV-Mainstreaming activities are aligned with Malawian policies: • For example: Care of the Carer Policy (2005)

4. Malawi: Health administration structure Formulation of Policies Supervision and Support to DHMT Operational level

5. Results-Based Evaluation of HIV Mainstreaming • Evaluation structured along the HIV MS results chain • Output Level: • Use of output level • Outcome level The goals of the initial country visits are as follows: (output and use of output) •  To meet with GTZ and DED country staff involved with HIV mainstreaming and to introduce the goals, methods and approach to the evaluation • To review the strategy, logic and approach behind HIV external mainstreaming interventions supported by the GTZ and DED in each country during 2008 and 2009 • To gather data for the output and use of output levels of the evaluation via semi-structured interviews with GDC staff, partner institutions, and national and international AIDS authorities • To determine, in cooperation with GTZ and DED personnel, a selection of up to 4 HIV mainstreaming interventions in each country which will be evaluated at the outcome level and to lay the groundwork for this stage of the evaluation

8. Evaluation Design SE Zone SW Zone Interim Outcomes at Institutional level: performance of Care of Carer structures and WPPs Individual level: no baseline data available. Intervention still in an early stage of intervention (Baseline June 2009, kick of in July 2009) Areas explored: (3 interim outcomes) WPP functioning at district hospitals in the Zone Hospital staff, across cadres, are aware of the WPP and Care of Carer policy HCW and other staff hold favorable views of the WPP and Care of Carer policy • Interim evaluation: preliminary results after first phase of support • Institutional level: performance of Care of Carer structures and WPPs • Individual level: changes in HCW knowledge, attitudes and behavior against baseline (Baseline study conducted by REACH Trust , 2008) • Areas explored: (5 interim outcomes) • WPP functioning • HCW awareness of Care of the Carer policy • HCW knowledge and behaviours related to occupational exposure and HIV risk • Uptake of HIV-related services • HIV-related stigma and discrimination

9. Methods used: SE Zone SW Zone Multi-level assessment using qualitative research methods Data collection at 1 District Hospital & 1 CHAM Hospital 3 main categories of respondents: Management HIV Implementers Hospital employees across cadres 8 semi structured interviews 7 focus group discussions (25 women, 18 men in the two facilities)  43 respondents • Multi-level assessment using qualitative and quantitative research methods • Data collection at 2 District Hospitals • 3 main categories of respondents: • Management • HIV Implementers • Hospital employees across cadres • 9 semi structured interviews • 1 focus group discussion (total of 6 women, 9 men in the two facilities) • 86 health care workers (58 women, 28 men) self -administered questionnaire (to mirror the original baseline survey approach in 2008 in which 92 HCWs were surveyed)

10. Findings in SW ZoneInterim Outcome 1: WPPs are functioning at district hospitals in the Zone (AWISA workplace model: 5 Pillars) There have been improvements across a range of Workplace program elements at both hospitals since baseline assessment.

11. Findings in SW ZoneInterim Outcome 2: Hospital staff, across cadres, are aware of the WPP and Care of Carer policy Hospital employees across cadres are aware of HIV related activities and services in the workplace, but do not necessarily associate these with HIV Workplace Program (WPP) and Care of the Carer policy. • Awareness about HIV related activities and services is high. Familiarity with the name of the WPP and the Care of the Carer Policy varied considerably. • Staff who are relatively new to the program were less familiar with the WPP and Care of the Carer Program. • Lower cadre staff were less aware of the WPP and Care of the Carer Policy (Policy is only available in English)

12. Findings in SW ZoneInterim Outcome 3: Health Care workers and other staff hold favorable views of the WPP and Care of Carer policy There have been improvements across a range of WPP elements at both hospitals since the baseline assessment. • Staff in different cadres have different concerns. Upper cadres: improved services; lower cadres: provision of monetary and/or nutritionally support • Perception that the WPP is only for employees who are directly or indirectly affected or infected with HIV. • Participation in workplace sessions depends on paying allowances. • HIV-related stigma and discrimination is reportedly high and continues to act as a barrier to service uptake.

13. Occupational Exposure Most HCWs now know that PEP is available at their facility Improved knowledge on purpose of PEP

14. Occupational Exposure

15. Occupational Exposure

16. Uptake of HIV-related Services • Reports of increased HCW uptake of HTC, ART, PEP • Slight increase from baseline in % of HCWs who have ever had HIV test (77% to 81%) • Perceived changes in willingness to test, as well as to test at own place of work • Increased testing has reportedly led to reduced absenteeism and better hospital performance • Factors: • Salary top-up is a big incentive to test • Sensitisation to Care of the Carer policy