Evaluation of HIV and AIDS Workplace Policy at Nkhotakota District Council, Malawi Researcher: Patrick Mbulaje, MPH, BSc. MLT Malawi AIDS Counselling and Resource Organisation, Malawi

The evaluation was conducted to find out whether the stipulated objectives of the policy are being followed, and at the same time find out whether the envisioned results of implementing such policy system have been achieved so far. The evaluation was expected to provide an opportunity for mending shortfalls of the whole system that would affect its sustainability and usefulness.A total of 33 participants were interviewed in this study and came from the study area (Nkhotakota District Council Office). Purposive sampling was used to select the participants. All study respondents were purposively selected where respondents considered having relevant information and they were interviewed to obtain wide range of perspectives.Seven themes were identified; knowledge on policy, limited stakeholder involvement, poor HIV and AIDS programming, ethical issues, future perspective of the policy, Other Recurrent Transaction (ORT) allocation, and availability of HIV and AIDS Committee. On knowledge on policy, the sub-themes included; objectives well outlined, and poor updates on the policy. On limited stakeholder involvement, the sub-themes were; lack of ownership, ignorance of involvement, and not involved/limited involvement. On the Poor HIV and AIDS programming theme, sub-themes identified were; exclusion of activities in the District Implementation Plan (DIP) and lack of funds. There was one sub-theme on ethical issues and future perspective.We found that the Nkhotakota District Council HIV and AIDS at workplace policy is not functioning properly due to poor coordination and lack of funding. However, there are some positives identified such as existence of the coordinating committee and allocation of funds through ORT. Although the system has been functional for some years in well-established structures, lack of participation by some stakeholders, non-inclusion of HIV and AIDS activities in the DIPs underpin its sustainability


INTRODUCTION
Evaluation as an analytical tool can be defined in two ways in the field of public policy. Firstly, evaluation involves investigating a policy to obtain all information pertinent to the assessment of its performance, in terms of both process and results. Secondly, evaluation as a phase of the policy cycle more generally refers to the reporting of such information back to the policy making process (1). The need to do an evaluation on HIV and AIDS policy is backed by the following: to create great awareness of the pandemic, improve stakeholder awareness to HIV and AIDS policy, and lastly to determine the policy contribution in reducing the impact of the pandemic.
Some HIV and AIDS policies have too much one-way communication, together with the lack of education based on scientific evidence, strategies and objectives or even policy documents, the lack of knowledge on how to implement a policy, the lack of gender and human rights perspectives, poor cooperation between different HIV and AIDS policy, and even lack of policy evaluation (7,8).
The study done at College of Medicine to identify gaps between policy and practice suggests that a lot of people do not know about the HIV and AIDS related policies mainly due to lack of interest and lack of knowledge (14).
Some of the notable factors that might hinder the implementation of the policy include; gender dimensions (lack of women empowerment), stigma and discrimination, and even lack of funds to properly run the Policy. It is assumed that despite the policy in place the employees do not know the issues in the policy like concerns regarding the impact of HIV and AIDS on their employment. (7) Evaluation is designed to analyse the impact and performance of the policy being utilized(16).
Evaluation enables an organization to assess its progress against stated goals and make decisions about how well interventions are succeeding. When performing the policy analysis the following criteria are looked at: Relevance of the policy, effectiveness, efficiency, impact of the interventions, sustainability of the policy(16).
The evaluation of the HIV policy at Nkhotakota District Council was conducted to find out whether the stipulated objectives of the policy are being followed, and at the same time find out whether the envisioned results of implementing such policy system have been achieved so far. The evaluation was expected to provide an opportunity for mending shortfalls of the whole system that would affect its sustainability and usefulness. The study will help to inform the District Council on the challenges being faced in utilising the policy and hence assist the team Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 28 April 2020 Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 28 April 2020 doi:10.20944/preprints202004.0493.v1 to fine tune them. Failure to do an evaluation on this policy can impact the performance of the policy as the mistakes can be repeated by the implementers.

METHODS
This was a cross-sectional study design. The study took place at Nkhotakota District Council Office which is located at the heart of Nkhotakota District, Central region of Malawi.
Purposive sampling was used to select the participants based on their knowledge or having relevant information on HIV policy. The participantsinterviewed to obtain wide range of perspectives.
Defining a prior sample size is beyond the scope of a qualitative study. The accepted technique used in qualitative research to determine sample size is that of saturation (17).
Data was analysed using content analysis, according to Elo and Kyngas (2008), data analysis goes further than description; it involves the use of technique to convert the data (18). Data from field notes were transcribed verbatim and transcription were read and re-read carefully to get general sense of the information and to reflect on the overall meaning. The themes that appeared were main findings of the study and are presented in narrative form.

RESULTS
A total of 33 participants from Nkhotakota District Council were interviewed.
Themes and sub themes were generated from study participants based on narrated experiences and feelings. The themes and sub themes are summarised in Table 1 below. There is minimal involvement of some stakeholders in the implementation of the HIV and AIDS policy at Nkhotakota District council even though the district has several of HIV and AIDS implementing partners. For instance, out of the 9 stakeholders in the District, its only Nkhotakota AIDS Society Organisation (distribution of nutritious foods) and District Health Office (offering HIV Testing and Counselling and ART services) involved in the policy.

Some stakeholders not involved
According to the District AIDS Coordinator, some stakeholders are open to helping the activities at the Council but the problem is due to the way other staff are handling themselves in terms of HIV activities.

"Banja La Mtsogolo and District Health Office are open to be supplying us with
HIV related supplies such as condoms and nutritious food but when you assign individuals to be coordinating such initiatives they only work for few weeks and abandon them due to lack of incentives"

Ignorance of the involvement
Some participants expressed ignorance of the policy and involvement of the stakeholders. The knowledge about the policy and its use was not known and the practice as well.
"I am not familiar with the policy apart from knowing that there is a committee and other organisations that assist the Council". Interview 9 (junior staff) Nkhotakota District has HIV and AIDS implementing organisations. The organisations are classified into Government, private, Non-Governmental, and Faith based. Refer to Table 2 below for the list of these organisations.

Poor HIV and AIDS Programming
The activities in relation to HIV and AIDS are not being financed by the District Council. This is making it difficult for the HIV programmes to be sustained.

Exclusion of HIV activates in District Implementation Plan
The subjects bemoaned the exclusion of the activities in the DIP most of the times.

Existence of HIV and AIDS coordinating committee
The district council has the HIV and AIDS coordinating committee that is championing HIV related activities including the policy. The committee was formed in 2010.

Members oriented at inception
The key informant pointed at the inception meeting as one of the strengths of the HIV and AIDS at workplace policy. He commended the Ministry of Labour officials for orienting the committee members before starting their duties.
"When the policy was introduced, we were asked to select Coordinating Committee members to champion the policy, the members were then oriented on the policy so as to easily perform their duties. The officials from Ministry of

No frequent meetings
The participants bemoaned lack of frequent meetings by the committee members as a challenge in implementation of the policy. They have a feeling that such meetings can help in rectifying some problems before they become chronic.
"You know it's difficult to meet frequently due to work commitments and lack of funds, it's true that last time we met was in August, 2015. We normally utilize the DEC meetings to slot our agendas in"-Committee member The study revealed that there is a certain allocation from ORT that carter for HIV and AIDS interventions.

K5, 000 provision to HIV positive employees
The committee member pointed at the K5, 000 that every HIV positive employee gets every month as a positive thing happening at the council with the policy.
"Honestly, we receive the K5, 000 every month without any problems, but this money is just too little to sustain us. The management should consider revising the rate to march the current economic status"junior staff member

2% of ORT utilised by departments
The participant explained that each and every department utilises 2% of its ORT allocation towards HIV and AIDS activities as per recommendation by the policy.
"We have proof that all the departments are utilising the 2% towards HIV activities such as visiting sick employees or their relatives"-Committee member

DISCUSSION
The study has established that the policy is not adequately being utilized though indicated that it is a useful tool in HIV and AIDS prevention. It has been observed that the policy is facing challenges that need to be addressed with urgency so that all the employees should benefit from this important policy.
The Nkhotakota District Council employees are not well acquainted with the policy. This is a major setback, as the majority of respondents has been in the employment for more than 2 years and should have been exposed to the policy in some way or another. This means that Nkhotakota district council has not yet reached all of their personnel with information on HIV and AIDS.
According to the World Health Organisation, policy enabling environment helps in addressing political, economic, social, and health issues. Failure to make the policies favourable to all individuals can disable uptake of services to a marked degree.

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The study highlights some of the challenges faced at the District Council in utilising the policy that must be considered to improve its operation. There is a need for leadership to recognise and support other staff to be familiar with the HIV and AIDS at workplace policy, properly finance HIV activities so as to achieve the objectives, and to develop a culture of courting stakeholders to help the implementation.
HIV and AIDS services in the workplace survey in four Sub Saharan African countries showed that a lot of companies even though they have the workplace policy in place they do not deliver or finance HIV and AIDS services on site (15). The findings from the study at Nkhotakota Council echoed with the study in the Sub Saharan African where the HIV and AIDS programs are not being financed and included in the DIP at the institution. The HIV programs need to be thoroughly financed to ensure sustainability.
A study among final year medical students at Hanoi medical university in Vietnam on knowledge of HIV and factors associated with attitudes towards HIV services showed that gaps still exist in stigma and discrimination, prevention, and care and treatment (22). This is in line with the findings from this study where privacy is a challenge at the District Health Office where people get medical help; the clients are able to access other people's information and hence facilitating the increase in stigma and discrimination. The DHO attributed the possible cause of lack of privacy to infrastructure problem as the ART clinic is housed in the Isolation Ward hence making it prone to unauthorised entry but he emphasised that the rooms are always locked and if any individual who feels that privacy is breached should immediately report to the hospital ombudsman for action. There is need to ensure that privacy is observed at all times to ensure that people trust the services that they are seeking without fear of a third party accessing their information and leading to cases of stigmatisation and discrimination.
The departments need to utilise 2% of their Other Recurrent Transaction towards HIV and AIDS workplace interventions, while mobilizing resources from development partners to supplement government funding. The adequate financing of HIV and AIDS workplace interventions and effective implementation of these interventions will contribute significantly towards the achievement of the MGDS and the Malawi Decent Work Country Programme (8).
Nkhotakota District Council departments are utilising the 2% of the ORT as per the study findings. The challenge is now to win the hearts of other partners to supplement on the little funding they have receive from Government on monthly basis. HIV positive employees are also able to get K5, 000 from the ORT allocation as monthly allowance to sustain themselves with some basic needs The District Council took a board step towards successful implementation of the HIV policy by bringing together a coordinating team to spearhead the policy. The selected members had to undergo an orientation meeting to sensitise them about the policy. The committee comprises cadres at all levels (senior and junior employees) so as to make it friendly to all employees.

CONCLUSION
The study reveals that the Nkhotakota District Council HIV and AIDS at workplace policy is facing challenges due to poor coordination and lack of funding. On a positive note, the council has a well-established coordinating team, and there is provision of 2% of ORT funds towards HIV and AIDS activities. Although the system has been functional for some years in wellestablished structures, lack of participation by some stakeholders, non-inclusion of HIV and AIDS activities in the DIPs underpin its sustainability. It is therefore recommended for the Council to strengthen the policy for it to start achieving its objectives. There is a need to periodically evaluate the policy to increase workers' motivation, quality of care and programme sustainability.
HIV and AIDS is a workplace issue and should be treated like any other serious condition that can affect the employees in the workplace, not only because it affects the workplace, but also because the workplace has a role to play in minimising the spread of the virus since the employees are part of the local community.