VOLUNTARY COUNSELLING AND TESTING (VCT) 
PROGRAM
IMPLEMENTED BY:
MALAWI AIDS COUNSELLING AND RESOURCE OGRANIZATION (MACRO)
(UMOYO Network GRANT NUMBER: UHN-0011-99-02)
FINAL EVALUATION REPORT
PREPARED BY:
Patricia Ziwa, USAID/Malawi
Mexon Nyirongo, USAID/Malawi
Allan Hackner, USAID/Pretoria
Draft 
September, 2004
ii
TABLE OF CONTENTS
ACCRONYMS.........................................................................................................................iii
PROJECT IDENTIFICATION DATA SHEET .................................................................. iv
ACKNOWLEDGEMENTS ....................................................................................................v
1.0 EXECUTIVE SUMMARY.........................................................................................1
2.0 INTRODUCTION.......................................................................................................2
2.1 Objectives.......................................................................................................................2
2.2 Background....................................................................................................................2
3.0 METHODOLOGY ......................................................................................................5
3.1 Questionnaire Design ....................................................................................................5
3.2 Choice of Field Sites......................................................................................................5
3.3 Identifying Key Informants (Sampling)..........................................................................6
3.4 Administering the Questionnaire (Data collection).......................................................6
3.5 Data Processing and Analysis .......................................................................................6
3.6 Institutional Capacity Index...........................................................................................7
3.7 Quality of VCT Services Index .......................................................................................8
4.0 KEY FINDINGS ..........................................................................................................8
5.0 CONCLUSIONS AND RECOMMENDATIONS...................................................23
6.0 ANNEXURES
ANNEX I: SCOPE OF WORK ...............................................................................................25
ANNEX II: MACRO EVALUATION QUESTIONNAIRE...................................................29
ANNEX III: LIST OF KEY INFORMANTS..........................................................................37
ANNEXES IV – VII: DATA TABLES ...................................................................................38
iii
ACCRONYMS
AIDS Acquired Immunodeficiency Syndrome
ARV Antiretroviral
CDC Centers for Disease Control and Prevention
CTO Cognizant Technical Officer
DHO District Health Officer
GTZ German Technical Support
HIV Human Immunodeficiency Virus
MACRO Malawi AIDS Counseling & Resource Organization
MDHS Malawi Demographic Health Services
MOHP Ministry of Health and Population
MSI Management Systems International
NAC National AIDS Commission
NAPHAM National Association of People Living with HIV/AIDS in Malawi
NGO Non Governmental Organization
PIVA Partner Institutional Viability Assessment
PTC Post Test Club
PMTCT Prevention of Mother to Child Transmission
RH Reproductive Health
SOW Scope of Work
STI Sexually Transmitted Infection
USAID United States Agency for International Development
VCT Voluntary Counseling & Testing
QECH Queen Elizabeth Central Hospital 
iv
PROJECT IDENTIFICATION DATA SHEET
Activity Name: Save the Children Federation Inc. - UMOYO Network 
Activity Number: 690-A-00-05-00185-00
Implementer: Malawi AIDS Counseling & Resource Organization 
(MACRO)
Funding Source (s): USAID through Umoyo Network
Life of Project: December 2001 to March 2003
Life of Project Funding: US$1,043,370.00
Project Location: Blantyre, Lilongwe, and Mzuzu
Activity Manager: Elise Jensen
v
ACKNOWLEDGEMENTS
The evaluation was conducted over the week of September 13 –17, 2004. Key informants and 
community members made themselves available for meetings and interviews often at very 
short notice. We would like to thank all who were involved in the evaluation process. It 
would not have been possible for the evaluation team to gather all the required data and 
information without the support of these people.
Special thanks go to NAPHAM, MACRO staff and support clubs, UMOYO network staff, 
Mulanje District Hospital DHO and staff, Mangochi District Hospital Deputy DHO and staff 
for the generous and important information they rendered to the team. They accepted to 
change their busy schedules in order to accommodate this evaluation exercise.
We would like to thank USAID/Malawi and USAID/Pretoria for providing funding for travel 
and other logistic support which made the whole evaluation possible.
Finally, we thank MSI and USAID/Washington for organizing this very important and 
beneficial course.
1
1.0 EXECUTIVE SUMMARY
This is a final evaluation report of Voluntary Counseling & Testing (VCT) services 
implemented by the Malawi AIDS Counseling and Resource Organization (MACRO), which 
is supported by Umoyo Network (Umoyo) under a grant management and technical 
assistance cooperative agreement funded by USAID/Malawi. The primary objective of the 
evaluation was to determine if institutional capacity building and technical support provided 
by Umoyo Network to MACRO has resulted in a significant increase in the quality and 
availability of voluntary counseling and testing at MACRO. The evaluation has drawn largely 
on the knowledge, attitudes and perceptions of management and staff at MACRO and 
Umoyo, as well as the experiences of clients.
The key conclusion emanating from this evaluation is that the overall institutional capacity 
and quality of VCT service delivery at MACRO has increased/improved due to Umoyo 
Network’s interventions since 1999. 
Despite this improvement/increase, a number of constraints affect the provision of VCT 
services. These include: fear of testing because of discrimination & stigmatization; 
communities not adequately sensitized and mobilized to support VCT and to accepting HIV
positive members of the community; insufficient counselors and inadequate counseling 
rooms; concerns about privacy and confidentiality; clients having to travel long distances for 
VCT services; inadequate and inconsistent flow of funds. 
It was found that fewer women than men use MACRO’s VCT services largely as a result of 
gender/cultural based issues - such as women having to seek consent from their husbands
before they go for VCT; and women being more prone to divorce if found HIV positive than 
men. Women are more likely to opt for VCT at integrated health care centers where family 
planning and anti-natal clinics are available and/or at out reach sites where it is easier to 
maintain anonymity and it is more convenient. 
In-order to address some of the constraints cited above, the evaluation team recommended 
that MACRO should intensify its search for more accessible land, and construct larger 
facilities that will accommodate the increasing demand for services, and at the same time 
address issues of confidentiality and privacy in the facility design (e.g. a separate entrance 
and exit; appropriate partitioning, fencing, supervised place for children to play, etc). 
MACRO should also consider the integration of VCT with other health care services which 
will make VCT a more attractive option for women. At the same time MACRO needs to 
interact more with men through civic education to combat the poor attendance of women at 
its VCT centers. 
MACRO should also recruit and train additional counselors and lab technicians in order to 
meet the increasing demand for services; ensure the workload is more manageable; reduce 
burnout and staff turnover; and offer services over lunch hours and early evenings.
Finally, USAID should consider ‘graduating’ MACRO from the Umoyo Network technical 
assistance program and provide direct support to MACRO.
2
2.0 INTRODUCTION 
This is a final evaluation of Voluntary Counseling & Testing (VCT) services implemented by 
the Malawi AIDS Counseling and Resource Organization MACRO, which is supported by 
Umoyo Network (Umoyo) under a grant management and technical assistance cooperative 
agreement funded by USAID/Malawi. The evaluation has been prepared as part of a 
USAID/Washington Evaluation Training Course and it focuses on determining whether or 
not Umoyo interventions to increase the institutional capacity of MACRO, has resulted in an 
improvement of VCT service delivery. The intended audience of this evaluation includes 
USAID, Umoyo, MACRO, the Malawi Department of Health, other donors, and scholars 
and/or any other interested parties within and outside Malawi, and the evaluation is intended 
to inform the design of a follow-on activity (See Annex 1 for the detailed Scope of Work).
2.1 Evaluation Objectives
The objectives of this evaluation are as follows:
a) to determine if Umoyo Network technical assistance and training has improved the 
overall institutional capacity of MACRO;
b) to determine if the quality and volume of VCT services have improved and increased 
as a result of the support from Umoyo; 
c) to inform the design of a follow-on activity; and 
d) to use the exercise as a learning experience.
2.2 Contextual Background
The overall picture of VCT for HIV in Malawi can best be understood in the context of 
current knowledge about HIV prevalence, government policy toward HIV prevention, care 
and treatment of those with HIV infection, government and private efforts to combat HIV 
transmission, and options for VCT services
2.2.1 Prevalence of HIV in Malawi1
The first hospital cases of AIDS in Malawi were diagnosed in 1985 (Cheesbrough, 1986), but 
they were preceded by an increased incidence of Kaposi’s sarcoma. According to John Lloyd 
Lwanda, the 2 percent prevalence rate of HIV discovered among antenatal patients at Queen 
Elizabeth Hospital in 1985 suggests that HIV may have arrived in Malawi around 1977 
(Lwanda, 2004). Prevalence rates among antenatal patients at that hospital subsequently 
increased rapidly, reaching 8 percent in 1987 and 19 percent in 1989 (Taha et al., 1998).
HIV spread rapidly among adults (15-49 years old) since the first case of AIDS was officially 
diagnosed in Malawi in 1985. AIDS has become the leading cause of death among adults 15-
49 years old, a group that makes up 44 percent of the total population. In fact, the death rate 
for adults 15-49 tripled between 1990 and 2003. Mortality from AIDS has reduced life 
expectancy from an estimated 52 to 42 years.
Malawi now ranks among the countries with the highest national prevalence rates of HIV in 
the world, but prevalence is not evenly distributed among adults by age or gender. In the age 
 
1
 Voluntary Counseling and Testing for HIV in Malawi: Public Perspectives and Recent VCT Experiences, P S 
Yoder, P M Matinga, June 2004.
3
group of 15 to 24, the HIV infection rate of females is twice that of males. Infection with HIV 
continues to be particularly high among adolescent girls.
In 2003, the National Aids Commission estimated that the national prevalence of HIV among 
adults was 14.4 percent, with a range from 12 to 17 percent. This range of HIV infection has 
remained constant for the last seven years. Estimates for the rural population and urban areas 
were 12.4 and 23.0 percent, respectively. The total number of infected adults was 760,000. 
There are also approximately 70,000 children under the age of 15 with HIV and 60,000 
people over the age of 50 who are infected
2.2.2 HIV Testing in Malawi
Many organizations, both public and private, have sought ways to prevent the spread of HIV 
in Malawi. Some groups have advocated the establishment of stand-alone centers or hospital 
departments that offer HIV testing along with counseling to avoid the risk of HIV, but few 
such centres exist. The Ministry of Health approved the use of rapid test kits for pilot studies 
in 2000, but it has been slow to allow the expanded use of rapid test kits. Experiences in a 
number of African countries have demonstrated that individuals will be far more likely to 
come for an HIV test if the results are available the same day.
There are currently both public and private centres able to conduct HIV testing and 
sometimes counseling, in the country. During the 2000 Malawi Demographic Health Surveys 
(MDHS), men and women were asked whether they had been tested for HIV and, of those 
who responded, 58% of women and 49% of men said they had been tsted in a public 
(government) facility. Thirty percent of women and 38% of men reported they had been 
tested in a private facility. Eight percent of women and 10% of men said they had gone to 
MACRO at their centers in Blantyre and Lilongwe.
2.2.3 MACRO Project Background
MACRO was established in 1995 to provide quality VCT services to enable people know 
their sero-status through stand alone facilities. The services are provided to individuals, 
families and communities to promote behavioral change in order to reduce the transmission 
of HIV and the impact of HIV/AIDS. Figure 1 below indicates the location of MACRO VCT 
sites in Malawi.
Figure 1
8
MAP OF MALAWI
ZAMBIA
TANZANIA
MOZAMBIQUE
MOZAMBIQUE 
MACRO LILONGWE
CENTRE
MACRO BLANTYRE CENTRE
MALAWI
MACRO MZUZU
CENTRE
4
The core values of MACRO are privacy, confidentiality, clients’ consent and human rights. 
These core values are achieved through the following:
ß Providing anonymous and confidential voluntary HIV counseling and testing.
ß Providing information on STI/HIV transmission.
ß Imparting behavioral change skills to prevent and reduce the transmission of STI/HIV.
ß Counseling individuals to cope and live positively with HIV and AIDS.
ß Providing treatment for STIs, Opportunistic Infections and family planning services 
appropriate to clients.
MACRO initially provided counseling services and referred all clients to Ministry of Health 
facilities for testing. This used to take a long time and many clients were disappointed with 
the process. With assistance of USAID and CDC, MACRO established its own Laboratory 
for testing. The tests were based on a new technology (Rapid Testing) which gave same day 
results. In order to prepare MACRO adequately for an anticipated increased demand for 
VCT services, Umoyo Network was engaged by USAID in September 1999 to strengthen and 
improve MACRO’s institutional capacity in order to improve the efficiency and quality of 
VCT service delivery. The project supports Strategic Objective 8 in the USAID/Malawi 
Country Plan for 2001-2005: “Behaviors adopted that reduce fertility and HIV/AIDS and 
improve child health”.
MACRO Project Objectives:
ß To strengthen and improve management and governance
ß To provide and improve quality of VCT services
ß To provide and improve quality of care to people living with HIV/AIDS
ß To mobilize communities to increase VCT demand by women
ß To strengthen and increase networking and linkages with other stakeholders
MACRO did not attract large numbers of clients until 2000. The MACRO annual report for 
2000 reported a major increase in the number of clients served, with each centre seeing 
serving more than 1000 clients per month. The increase is attributed in part to the 
introduction of whole-blood rapid HIV test kits to its centers in January 2000, improvement 
in its management capacity and advertising. October 2002 to October 2003 shows that the 
number of clients has continued to increase (Malawi AIDS Counseling and Resource 
Organization 2003). During this reporting period, the three MACRO facilities served 51,178 
clients: 18,841 in Blantyre, 17,840 in Lilongwe, and 14,497 in Mzuzu. These figures included 
1,060 couples who came for testing and counseling. Clients at these VCT facilities tend to be 
younger; 62 percent of MACRO clients for this period were 15 to 29 years old. The reports 
also show that the male/female ratio was closer to 2/1 than 3/1 during 2000. . 
5
3.0 METHODOLOGY
The study was conducted between September 13 and September 17, 2004 by a team 
consisting of two USAID/Malawi officials and one USAID/South Africa official, with 
technical direction and advice from USAID/Washington and Management Systems 
International(MSI). The evaluation sought to answer the following key questions: 
a) Has the institutional capacity of MACRO changed?
b) Have services provided by MACRO changed for the better (increased/reached more 
people (access)/ improved in quality terms)?
c) Was the change in MACRO services a demonstrable result of a change in that 
MACRO’s capacity, i.e. can a link be proven? What unintended events have helped or 
hindered the delivery of quality VCT services?
d) Are beneficiary lives better off because of the services MACRO provided, i.e., do 
beneficiaries view the services as being appropriate to/important for meeting their 
needs?
e) Why do fewer women than men use VCT services?
f) Do clients referred by MACRO to treatment and support centers actually go to these 
centers for help?
Answering these questions required several steps, including: 
ß Designing the Questionnaires 
ß Selecting the field sites 
ß Identifying key informants (Sampling)
ß Administering the questionnaire (Data Collection)
ß Processing and Analyzing the data 
ß Reporting on the findings. 
3.1 Questionnaire Design
The study began with a desk top review of documentation on the MACRO project and HIV 
prevalence and treatment in Malawi, as well as tools and techniques for assessing NGO 
institutional capacity and evaluating HIV VCT services. The desk review led to the 
development of a questionnaire comprising an institutional capacity index; an index to 
evaluate the quality of HIV voluntary counseling and testing; and a series of structured open 
ended and closed questions (See Annex II). 
3.2 Choice of Field Sites
Since it was not possible to visit all three MACRO centers within the timeframe and 
resources available, the Blantyre MACRO was chosen because ofits proximity to Umoyo
Network headquarters (also located in Blantyre) and the fact that it is managed by the only
MACRO centre manager who was at the inception of MACRO and who has continued with 
the organization after the Umoyo Network intervention. In addition Mulanje and Mangochi 
6
district hospitals were selected to provide additional information on the HIV treatment 
referral system in Malawi and the support services available to MACRO clients. 
 
3.3 Identifying Key Informants (Sampling)
Key informants from USAID/ Malawi, MACRO; Umoyo Network; HIV support groups, and 
Mulanje and Mangochi district hospitals were identified in order to provide different 
perspectives on MACRO institutional capacity and service delivery. Key informants were 
selected because of their specific roles in providing technical assistance and training to 
MACRO, and/or their responsibilities at MACRO. All support group members coming to 
their usual weekly meetings were included in the discussion groups. (See Annex III for list of 
key informants)
The previous USAID CTO for the Umoyo Network activity was interviewed to assess the 
strength of MACRO before and after Umoyo intervention. The regional coordinator and five 
members of staff from Umoyo were interviewed to assess how they perceived the 
improvements MACRO had achieved with their assistance. At MACRO, the centre manager 
and eight staff members that were available at the center in Blantyre were interviewed to 
assess if they thought Umoyo intervention had made a difference in their operation. Three 
support groups were interviewed to assess their level of satisfaction with services offered by 
MACRO. The District Health Officer in Mulanje and the Deputy HIV/AIDS Officer in 
Mangochi were interviewed and to assess their views on the availability VCT and HIV/AIDS 
treatment in the region; the impact of MACRO in meeting VCT needs; and to understand the 
HIV treatment and support referral system. 
3.4 Administering the Questionnaire (Data collection)
Once the questionnaire was designed and fine-tuned, appointments were made with various 
individuals or groups. Where appropriate the interviews were conducted in both English and 
Chichewa. For the USAID, Umoyo Network and MACRO interviewees, the questionnaires 
were filled in by respondents. In the case of the support groups structure questions were 
discussed in a group and the number of respondents agreeing or disagreeing with a specific 
question s were given by show of hands. The numbers were recorded against relevant 
questions. In Mulanje and Mangochi, structured interviews were also conducted and notes 
recorded by each of the team members separately. After each interview/group discussion the 
team re-grouped and consolidated their findings.
3.5 Data Processing and Analysis
3.5.1 Data Management
At the end of each interview/discussion, the team ensured that all questionnaires were 
complete; Open-ended responses were post-coded; 
All data were entered accurately and carefully.
3.5.2 Cleaning & Verification
The team ensured that all values were in correct rows and columns;
Missing information was kept to an absolute minimum;
For each variable, all values were labeled correctly.
7
3.5.3 Data Analysis
The team used Descriptive and Causal Analysis, looking at occurrence and contributory 
factors of the responses given etc. (frequencies and cross-tabs);
Predictive Analysis was avoided as much as possible i.e. projections on the information given 
etc.
3.5.4 Inference
The team made conclusions based on evidence and first-hand information;
The team also made some statements about a particular sample studied e.g. section on clients’ 
satisfaction which included members of NAPHAM and Support Clubs;
The team was also able to make statements beyond the sample actually studied.
3.6 Institutional Capacity Index 
In order to determine if there has been a change in the institutional capacity of MACRO an 
adaptation of the USAID Regional Partner Institutional Viability Assessment (PIVA) Index 
was used.2
 The PIVA index is a participatory rapid assessment tool used to evaluate and 
monitor performance of six organizational systems, namely: governance, operations and 
management, human resources development, financial management, service delivery and 
external relations. Each of the six competency area is further divided into subcategories. For 
the purposes of this evaluation the PIVA index was modified to include financial 
management as a subcategory under Operations and Management. Key informants from 
USAID, Umoyo Network and MACRO were requested to score each of the institutional 
competency subcategories for MACRO, on a scale from one to five, for the period prior to 
the Umoyo Network grant management and technical assistance award in 1999, and for the 
period subsequent to the award. A score of (1) indicates a very low level of development;
(2) a low level of development (3) a fair level of development (4) an advanced management 
system and competency and (5) represents a very advanced management system and 
competency in a particular sub category. (See Annexure A: MACRO Evaluation 
Questionnaire). The numerical scores for each of the subcategories, by organization, were 
then averaged for a total score for each of the five competency areas. The total scores for the 
competency areas were then totaled and averaged for MACROs overall institutional capacity 
rating for both before and after the Umoyo award. The percentage change for each 
subcategory, by organization was then calculated as well as the percentage change in the 
overall level of institutional capacity following the Umoyo grant management and technical 
assistance award. 
 
2
 User’s Guide to the USAID/REDSO/ESO Regional Partner Institutional Viability (PIVA ) Index, December 
2001 Draft, For Review/Comments. 
8
3.7 Quality of VCT Services Index
In order to determine if services provided by MACRO have improved for the better an index 
to evaluate the quality of HIV voluntary counseling and testing (VCT) was developed, 
drawing on guidance outlined in UNAIDS’ “Tools for Evaluating HIV Voluntary Counseling 
and Testing".3
 The quality of VCT services index was designed as a participatory rapid 
assessment tool to evaluate performance of nine operational aspects of the VCT site and 
services, namely HIV testing and counseling services (pretest counseling, HIV testing and 
post test counseling); adherence to HIV testing and counseling procedures; accessibility and 
convenience (hours of operation and location); privacy; waiting area (ventilation); 
confidentiality; quality control; medical waste disposal & infection control; training; and 
supervision. Certain of the nine competency areas were further divided into subcategories. 
Key informants from USAID, Umoyo Network and MACRO were requested to score each of 
the VCT operational areas and subcategories for MACRO, on a scale from one to five, for the 
period prior to the Umoyo Network grant management and technical assistance award in 
1999, and for the period subsequent to the award. A score of (1) indicates a very poor level 
of service provision and competency (2) a poor level of service provision and competency
(3) a fair level of service provision and competency (4) a good level of service provision and 
competency and (5) represents a very good level of service provision and competency in a 
category or sub category. (See Annexure A: MACRO Evaluation Questionnaire). The 
numerical scores for each of the subcategories, by organization, were then averaged for a
total score for each of the nine competency areas. The total scores for the competency areas 
were then totaled and averaged for MACRO’s overall quality of VCT services rating for both 
before and after the UMOYO award. The percentage change for each subcategory, by 
organization was then calculated as well as the percentage change in the overall level of 
quality of VCT services following the Umoyo grant management and technical assistance 
award. 
In addition to the VCT quality of services index, key informant interviews and desk top 
reviews were conducted to in order to determine and compare the level of service provision 
and utilization over a twelve month period prior to the Umoyo Cooperative Agreement award 
with the level of service and utilization over the last twelve month period of the Cooperative 
Agreement. 
3.8. Data Limitations
The institutional capacity and quality of service indices, referred to above, depend on the 
respondent’s ability to recall events and information from before 1999. As such responses are 
likely to be influenced by the extent to which respondents can accurately recall events from 
over five years ago. This limitation is addressed to some extent by using average scores and 
getting a ‘triangulation’ of views from different organizations so that a more generalized
picture of events is established.
 
3
 Tools for Evaluating HIV Voluntary Counseling and Testing, UNAIDS Best Practice Collection, Geneva, 
Switzerland, May 2000.
9
4.0 KEY FINDINGS
4.1 Has the Institutional Capacity of MACRO Changed? 
In order to determine if there has been a change in the institutional capacity of MACRO an 
adaptation of the USAID Regional Partner Institutional Viability Assessment (PIVA) Index 
was used. (Refer section 3.6 above).
The overall combined Umoyo, MACRO and USAID institutional capacity rating for 
MACRO increased by 51% from 2.5 (poor level of capacity) for the period before the Umoyo 
grant management and technical assistance award, to 3.8 (fair to good level of capacity) for 
the period since Umoyo has provided assistance to MACRO. Program Delivery has shown 
the greatest change with the combined rating increasing by 79% from 2.2 to 3.9. External 
Relations, has shown the smallest change with the combined rating increasing by only 37% 
from 2.6 to 3.6. External Relations also has the lowest rating for the period after the Umoyo 
award. A summary of the overall combined MACRO, Umoyo, and USAID institutional 
capacity ratings is presented in Figure 2 and Table 1 below.
Figure 2
INSTITUTIONAL CAPACITY AFTER UMOYO
PERCENTAGE CHANGE 
0
10
20
30
40
50
60
70
80
90
Governance Ops
Management
Human
Resources
Program
Delivery
External
Relations
Institution
Competency
COMBINED RATING
 Table 1
OVERALL INSTITUTIONAL CAPACITY (N=14)
(Combined UMOYO MACRO & USAID rating)
COMPETENCY BEFORE UMOYO AFTER UMOYO % CHANGE
Governance 2.4 3.9 61
Ops Management 2.5 3.7 49
Human Resources 2.7 3.7 40
Program Delivery 2.2 3.9 79
External Relations 2.6 3.6 37
Institutional Competency 2.5 3.8 51
Umoyo’s overall rating of MACRO increased by 83% from 2.1 to 3.8, whereas MACRO’s 
overall rating of itself only increased by 21% from 3.1 to 3.8. USAID’s overall rating of 
MACRO increased by 43%, from 2.5 to 3.6. A summary of the percentage change in the 
rating of institutional capacity before and after the Umoyo grant management and technical 
assistance award, by organization, is presented in Table 2 and Figure2 below. 
10
Table 2
PERCENTAGE CHANGE IN INSTITUTIONAL CAPACITY BY ORGANIZATION
UMOYO (N=4) MACRO (N=9) USAID (N=1)
Governance 84% 6% 100%
Ops Management 93% 21% 50%
Human Resources 77% 30% 22%
Program Delivery 88% 31% 75%
External Relations 75% 21% 26%
Institutional Competency 83% 21% 43%
Figure 3
INSTITUTIONAL CAPACITY AFTER UMOYO
PERCENTAGE CHANGE 
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Governance Ops
Management
Human
Resources
Program
Delivery
External
Relations
Institution
Competency
UMOYO
MACRO 
USAID
Whereas Umoyo, MACRO and USAID each differ on MACRO’s overall level of 
institutional capacity prior to the Umoyo award, all three organizations have similar ratings of 
MACRO’s current overall level of institutional capacity. Except for human resource capacity,
MACRO rated itself highest on all institutional competency areas prior to the Umoyo 
intervention. As could be expected MACRO has a more positive view of its institutional 
capacity prior to the Umoyo intervention than does either Umoyo or USAID. (See Annex IV 
for a summary of the rating of Institutional Capacity before the Umoyo award and after the 
Umoyo award, by organization). 
Although the overall combined rating for each of the five competency areas and related 
subcategories increased for the period after the Umoyo award, MACRO’s rating for some 
subcategories decreased. MACRO’s rating of the Governing Body decreased by 12% from 
3.3 to 2.9; Leadership decreased by 17% from 4.0 to 3.3; Team Development and Conflict 
Resolution decreased by 9% from 3.6 to 3.2; and Private Sector Collaboration decreased by 
8% from 3.4 to 3.1. (See Annexure V for a summary of the percentage change by 
subcategory).
4.2 Have the Services Provided by MACRO Improved for the Better?
In order to determine if services provided by MACRO have improved for the better an index 
to evaluate the quality of HIV voluntary counseling and testing (VCT) was developed, 
drawing on guidance outlined in UNAIDS’ “Tools for Evaluating HIV Voluntary Counseling 
and Testing" (Refer section 3.7 above)
11
4.2.1 Overall Quality of VCT Services 
The overall combined Umoyo, MACRO and USAID quality of VCT services rating for 
MACRO increased by 64% from 2.2 (poor level of service) for the period before the Umoyo 
award, to 3.6 (fair to good level of service) for the period subsequent to the Umoyo award. A 
summary of the overall VCT quality of service ratings is presented in Fig 4 & Table 3 below.
Figure 4
QUALITY OF SERVICES AFTER UMOYA
 PERCENTAGE CHANGE
0 20 40 60 80 100 120 140
HIV Services
HIV Procedures
Accessibilty 
Privacy
Waiting Area
Confidentiality
Quality Control
Waste Disposal 
Training
Supervision
Overall Quality 
COMBINED
MACRO UMOYO
USAID RATING
Table 3
OVERALL QUALITY OF VCT SERVICE (N = 14)
COMPETENCY BEFORE UMOYO AFTER UMOYO % CHANGE
HIV Services 2.8 3.9 40
HIV Procedures 2.6 4.3 66
Accessibility and Convenience 2.6 3.5 33
Privacy 2.9 4.2 45
Waiting Area 2.6 3.7 39
Confidentiality 3.8 4.8 29
Quality Control 1.7 3.9 123
Waste Disposal & Infection Control 2.4 3.9 62
Training 1.8 3.5 96
Supervision 1.9 4.0 113
Overall Quality of Services 2.2 3.6 64
Quality Control and Supervision have shown the greatest changes with the combined rating 
for each increasing by 123% and 113% respectively. Both these competency areas had very 
low scores for the period before Umoyo assistance and their scores increased substantially for 
the period after Umoyo assistance. Confidentiality and Accessibility & Convenience have 
shown the smallest changes, increasing by only 29% and 33% respectively. Whereas 
Confidentiality had the highest score of 3.8 for the period before the Umoyo award, 
Accessibility & Convenience had a score of only 2.6. (See Annex VI for a summary of the 
rating of VCT Quality of Service before the Umoyo award and after the Umoyo award, by 
organization). 
Umoyo and USAID overall ratings of MACRO each increased by 111%, from 1.9 to 4.0 and 
1.8 to 3.9 respectively. MACRO’s overall rating of itself only increased by 15% percent from 
2.8 to 3.2. A summary of the percentage change in the ratings of quality of VCT service 
12
before and after the Umoyo grant management and technical assistance award, by 
organization, is presented in Table 4 and Figure5 below. (See Annexure VII for a summary of 
the percentage change by subcategory)
Table 4
PERCENTAGE CHANGE IN QUALITY OF SERVICES
COMPETENCY UMOYO (N=4) MACRO (N=9) USAID (N=1)
HIV Testing and Counseling Services 62% 28%
Adherence to HIV Procedures 66% 35% 117%
Accessibility and Convenience 33% 7% 75%
Privacy 67% 22%
Waiting Area 25% 9% 200%
Confidentiality 36% 0% 67%
Quality Control 71% 147% 200%
Waste Disposal & Infection Control 100% 12% 200%
Training 215% 27%
Supervision 133% 65% 150%
Overall Quality of Services 111% 15% 111%
Figure 5
QUALITY OF SERVICES AFTER UMOYA
 PERCENTAGE CHANGE
0 50 100 150 200 250
HIV Services
HIV Procedures
Accessibilty 
Privacy
Waiting Area
Confidentiality
Quality Control
Waste Disposal 
Training
Supervision
Overall Quality 
USAID
MACRO
UMOYO
4.2.2. HIV Testing and Counseling Services 
The overall combined rating for HIV Testing and Counseling Services increased by 40%
from 2.8 to 3.9. The rating by Umoyo of MACRO increased by 62% whereas the rating by 
MACRO of itself increased by 28%.
Respondents indicated that before Umoyo the time interval between taking blood and results 
being available could take between 7 to 10 days. With assistance from Umoyo, MACRO has 
been able to introduce rapid testing kits and results are now available within 15 to 30 
minutes.
13
 
 
The level of VCT utilization has increased significantly since the Umoyo Network 
cooperative agreement award. Table 5 below compares the level of service provision and 
utilization over the twelve month period immediately prior to the Umoyo award, with the 
level of service provision and utilization for the twelve month period August 2002 to August 
2003.4
 In the twelve months prior to the Umoyo award approximately 3,500 people presented 
at the centre. In the twelve month period August 2002 to August 2003 approximately 51,000 
people presented at the centre, a one thousand three hundred and fifty percent increase. 
Figure 6 indicates the demand for VCT at MACRO centre since 1992.5
 The demand for VCT 
increases significantly after 1999 when the Umoyo Cooperative Agreement was awarded. 
There is a slight decrease in demand in 2003 reflecting the advent of other VCT service 
providers in Malawi. 
Table 5
LEVEL OF UTILIZATION BEFORE UMOYO AFTER UMOYO
No. of people presenting at the centre 3,493 51,018
No. of people having pretest counseling 3,318 48,467
No. of people tested for HIV 3,318 48,467
No. of people returning for their results 2,323 (70%) 47,982 (99%)
No. of people receiving on going counseling < 2% > 4%
No. of people referred to other services < 100 1,932 (Aug 03 to Aug 04)
Figure 6
DEMAND FOR VCT AT MACRO CENTRES
61 296 394 776 1260 1699 3493 5663
21498
40806
51018 48000
-20000
-10000
0
10000
20000
30000
40000
50000
60000
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
 
4
 MACRO statistics provide by the Centre Manager
5
 Voluntary Counseling and Testing Best Practices, Malawi AIDS Counseling & Resource Organization, by 
Katawa Msowoya MACRO Blantyre, Updated 23/08/ 2004
Testing for HIV using rapid test kit Couple receiving post test counseling
14
4.2.3 Adherence to HIV VCT Procedures 
The overall combined rating for Adherence to HIV VCT Procedures increased by 66% from 
2.6 to 4.3. Umoyo’s rating of MACRO increased by 66%, MACRO’s rating increased by 
35% and USAID’s rating increased by 117%.
Respondents noted that although HIV testing and counseling procedures did exist at MACRO 
prior to the Umoyo award, these were based on a mixture of regional and international 
practices. Since the Umoyo award the procedures have been refined and are now based on 
national procedures and national guidelines. There is now an HIV testing algorithm 
(protocol) in place.
4.2.4 Accessibility and Convenience
The overall combined rating for Accessibility and Convenience increased by 33% from 2.6 to 
3.5. Umoyo’s rating of MACRO increased by 33%, MACRO’s rating increased by 7% and 
USAID’s rating increased by 75%.
Respondent indicated that VCT services are not offered during lunch hours or early evenings 
and it is therefore difficult for working people to benefit from MACRO services. It was 
suggested that the number of counselors should be increased so that the centre can be opened 
over lunch hours and late in the evening. It was also mentioned that there is no supervised 
place for children to play making it inconvenient for mothers with young children to be tested 
and counseled. 
It was noted that although the centre is on a main road not far from the most densely 
populated township, it is not easily accessible as people have to change busses to access the 
facility. The distance that people have to travel to the site was mentioned as a factor 
contributing to the higher percentage of youth that make use of the facility as youth tend to 
find it easier to travel longer distances than older people. It was felt that the space at centre is 
too limited, making it difficult for convenient storage of records and files, and restricting 
further expansion of VCT services. 
It was noted however that the site is well situated for referrals to other HIV service providers 
such as Queens Hospital and NAPHAM.
4.2.5 Medical Waste Disposal & Infection Control 
The overall combined rating for Medical Waste Disposal & Infection Control 
increased by 62% from 2.4 to 3.9. Umoyo’s rating of MACRO increased by 100%, 
MACRO’s rating increased by 12% and USAID’s rating increased by 200%.
Respondents noted that before Umoyo basic medical waste disposal procedure were in place, 
but these were not adequate. In the past insufficient bins were available for disposing of 
sharps, needles etc and disposal bins were old. Insufficient vehicles meant waste would 
remain on the site for quite some time before being disposed. Now there are sufficient 
resources to ensure this is done timely. Furthermore there are guidelines for waste 
management in place. Waste is typically disposed of through incineration at the nearby 
hospital and health centers. 
15
Respondents indicated that before Umoyo the procedures for infection prevention were not
strictly followed. Now infection prevention procedures are documented and followed,
coupled with the quality management system in place. Gloves are used during testing, 
running water is ensured at all times, essential supplies such as JIK, soap other disinfectants
are available, and protocols adhered to. Staff members have received training in infection 
prevention. One responded noted however that no Hepatitis B Vaccine is available for staff 
members who handle blood.
4.2.6 HIV Testing Quality Control
The overall combined rating for HIV Testing Quality Control increased by 123% from 1.7 to 
3.9. Umoyo’s rating of MACRO increased by 71%, MACRO’s rating increased by 147% and 
USAID’s rating increased by 200%.
According to respondents, prior to Umoyo, batches of tests were sent to QTEC for 
confirmation of results, but this was not done very systematically. Quality control now is 
standardized and there are protocols and guidelines being followed. Confirmation of test 
results is now done on site, and 5% of blood samples are sent to the central laboratory for 
quality assurance. Random tests of the test kits themselves are also conducted. There is also a 
person specifically tasked with performance monitoring and ensuring the quality of each 
MACRO site.
4.2.7 Privacy 
The overall combined rating for Privacy increased by 45% from 2.9 to 4.2 Umoyo’s rating of 
MACRO increased by 67% and MACRO’s rating increased by 22%.
Funding from Umoyo has enabled MACRO to expand into a second building. One building is 
used for administration and the other is used for VCT. In addition UMOYO provided funding 
for internal partitioning which has improved privacy. 
4.2.8 Confidentiality 
The overall combined rating for Confidentiality increased by 29% from 3.8 to 4.8. Umoyo’s 
rating of MACRO increased by 36%, MACRO’s rating remained unchanged and USAID’s 
rating increased by 67%.
One respondent noted that confidentiality is compromised by clients having to enter and 
leave the facility through the same door. A separate entrance and more private exit would 
improve the sense of privacy and confidentiality. It was also pointed out that confidentiality 
is compromised because of the proximity of the site to the road and the absence of a fence. 
4.2.9 Supervision
The overall combined rating for Supervision increased by 113% from 1.9 to 4.0. Umoyo’s 
rating of MACRO increased by 133%, MACRO’s rating increased by 65% and USAID’s 
rating increased by 150%.
According to respondents supervision was not very good before Umoyo as there were fewer 
staff with little training in VCT management. Since Umoyo supervision has improved. 
Respondents indicated that supervision is usually provide on a quarterly basis and is mainly 
focused on delivery of services to ensure quality. One respondent stated that supervision is 
16
more focused on ensuring proper documentation rather than finding measures to address 
weaknesses.
4.2.10 Training
The overall combined rating for Training increased by 96% from 1.8 to 3.5. Umoyo’s rating 
of MACRO increased by 215%, and MACRO’s rating increased by only 27%.
Umoyo provides training in the following areas for MACRO management and employees: 
Post test counseling; HIV testing; VCT site management; VCT supervisor training; STI 
training; PMCT training; Monitoring & Evaluation; Financial Management; Finance and 
USAID Regulations; Strategic Planning; Infection Prevention; Stress Management; Proposal 
Writing; Psycho/Social Positive Living. 
Whilst some respondents indicated that they had never received any of the above training 
most stressed the need for ongoing training in these areas with particular emphasis on a more 
‘sydromatic approach’ to treatment of STI’s and a more integrated approach to managing 
STIs, HIV, PMCT and positive living. The need for training in report/proposal writing and 
computer skills was also noted. 
4.3 Was the change in MACRO services a demonstrable result of a change in 
MACRO’s capacity, i.e. can a link be proven? What unintended events have 
helped or hindered the delivery of quality VCT services?
4.3.1 The Link Between Umoyo and Improvement in Service Delivery
Respondents were asked if they thought the quality of service delivery has improved as a 
direct result of the technical assistance and training provided by Umoyo Network to 
MACRO. 80% of respondents indicated that MACRO’s VCT services have improved as a 
result of the technical assistance, funding and training provided by Umoyo Network. These 
respondents noted that as a result of Umoyo, MACRO now has a clear vision, expansion 
strategy, and action plans in place. Respondents indicated that Umoyo has time and again 
assisted MACRO in training its counselors. The knowledge and skills acquired from this 
training have contributed to improved service delivery. Logistical support like issuance of 
test kits to provide continuity of services has also resulted in an increase in the numbers of 
clients seeking VCT services.
4.3.2 Other reasons for the improvement in the quality of VCT service delivery
Whereas 53% of respondents identified improvements in quality of services as being due 
only to Umoyo interventions, about 27% of the respondents felt that the improvement in 
quality of services was due to both Umoyo and other factors. Some respondents stated that 
improvements were also due to staff members upgrading themselves, not necessarily with 
Umoyo assistance. It was noted that the introduction of rapid testing has resulted in a 
tremendous improvement in the quality of VCT service delivery. Other reasons included: 
better management; adherence to national standards; services provided by trained staff; 
introduction of mechanisms for monitoring and ensuring quality; exposure to in-service 
training courses; mid-term and annual review meetings; weekly counselor meetings; and 
counselor exchange meetings. (Many of these reasons could however be attributed to the 
assistance provided by Umoyo). Another reason given was that a number of VCT centers 
17
supported by other institutions have opened up and this has forced MACRO to improve its 
services in order to be competitive. Findings are presented in Figure 7 below:
Figure 7
IMPROVEMENT IN QUALITY OF VCT SERVICES AS 
A DIRECT RESULT OF UMOYO 
53%
27%
20%
Improvement only
due to Umoyo
Improvement due to
Umoyo and other
factors
No response 
4.3.3 Hindrances to the delivery of more improved service delivery
High staff turn over was noted to be one of the major issues impeding improved quality of 
service delivery. Poor salary packages and other incentives were identified as the main 
reason for high staff turnover; and that staff members leave as soon as they acquire the 
training and experience to upgrade themselves. Another major issue noted is inadequate 
infrastructure to cater for increasing demand i.e. there are too few counseling rooms and 
insufficient counselors, as such people have to wait long hours in order to see a counselor. It 
was noted that MACRO has sourced funds to construct good offices but have not yet 
managed to acquire land. The lack of availability of essential supplies and equipment was 
also given as a reason. A few people mentioned that lack of direct funding to MACRO is a 
hindrance to more improved service delivery. Findings are presented in Figure 8 below:
Figure 8
FACTORS HINDERING MORE 
IMPROVED SERVICE DELIVERY
20%
24%
20%
16%
20%
Inadequate
resources
High staff turnover
Inadequate and
poor infrastructure
Shortage of
Counsellors
Other**
**
Lack of Civic Education to the rural masses
Lack of incentives (e.g. transportation costs)
Some planned activities are not funded by NAC
Stock-outs of essential supplies/lack of availability of test kits
18
4.4 Are beneficiary lives better off because of the services MACRO provided, i.e., do 
beneficiaries view the services as being appropriate to/important for meeting their 
needs?
MACRO refers Voluntary Counseling and Testing (VCT) clients to three HIV support
groups, namely: the Post Test Club; the Young Ambassadors, and the National Association of 
People Living with HIV-AIDS in Malawi (NAPHAM). These groups have developed their
own capacities to counsel others and advocate for VCT, but they are largely dependent on
MACRO for referrals and/or resources. The degree of satisfaction with MACRO services
tends to vary. 
4.4.1 Post Test Club and Youth Ambassadors
The Post Test Club (PTC)) comprises members who have undergone VCT and know their 
serostatus but have not disclosed it to the general public. They are supported by MACRO to 
increase awareness on the causes and prevention of HIV/AIDS. They are provided with
transport and allowances for outreach activities. The group meets every Wednesday to
provide each other with the necessary support to live positively with HIV/AIDS. They
discuss many HIV/AIDS related issues including sexuality, family planning, and home based
care. 
The Youth Ambassadors comprise a group of young people aged between 13 and 29 years 
who have gone through VCT and know their sero-status to be positive and have come in the 
open to declare their status. Their membership is currently at 10. Three of them work as VCT 
councilors at QECH and the other seven provide out reach to advocate for VCT and positive 
living with HIV/AIDS. They give testimonies about how they have benefited from knowing
their status. 
The Young Ambassadors work from
MACRO offices but do not have as
much support from MACRO as do the 
PTC members. They receive assistance
from such organizations as UNICEF,
UNFPA, NAC and GTZ. Sometimes
funding is difficult to find resulting in
activities being curtailed. Due to age
differences, this group has not
associated itself with the National
Association of People Living with
HIV/AIDS in Malawi (NAPHAM),
whose members tend to be older.
The evaluation team held a joint group discussion with members from both the Post Test 
Club and Youth Ambassadors. Of the 19 members that were interviewed, 8 (42%) knew
about the existence of MACRO through radio, 5 (23%) through friends, 7 (37%) from other 
Post Test Club members, and 1 (5%) knew through a poster. There was a general comfort 
level with the MACRO counselors who counseled the members. Out of the 19 members, 11 
(58%) were comfortable with their counselor. All the members interviewed were satisfied
with the level of privacy although 4 (21%) members preferred same sex counselors. One
Members of the Post Test Club and Youth 
Ambassadors
19
member nevertheless felt uneasy when a third party attended the counseling session. When it 
was later explained that the third party was on training, the client regained confidence with
the counseling. Otherwise all members preferred the same counselor for pre and post test. 
PTC members noted that the information provided by the MACRO councilors ranged from
risk reduction to positive living with HIV/AIDS. All the members found this information
useful and desirable. As an indication of their satisfaction with MACRO VCT services, all
members expressed willingness to recommend these services to a friend or relative who may
have been engaged in risky behavior. All members confirmed they have recommended others 
to go for VCT.
4.4.2 People Living With HIV/AIDS
This group comprises members of staff of NAPHAM and the general membership of people 
who have tested positive for HIV. Some have reached symptomatic AIDS while others are
not showing symptoms. Membership has increased from 51 in October 2003 to 260 in August 
2004. The increase is attributed to the availability of ARVs. This group provides members
with material and spiritual support. Their Friday session begins with gospel praise songs,
prayers and preaching then drifts into individual problem recitation. There are lengthy
discussions which focus on real life problems which members have experienced. Members
attempt to assist each other as much as they can. This group also has a strong link with
MACRO with 182 of the 260 members having being referred from MACRO. The group has 1 
employed counselor and 10 volunteer counselors who have received a two-week training
course. NAPHAM members are strong advocates of VCT and positive living. They also
advocate family planning and use of condoms.
Out of 260 members, there are only 10 youths. It was indicated that most youth feel that 
NAPHAM is for the older folks, and as such the youth tend to be more affiliated to MACRO 
from where the Post Test Club and Youth Ambassadors operate. While a strong link is
maintained between NAPHAM and MACRO, members feel that MACRO has sometimes
acted unprofessionally. It was noted that some members of MACRO staff were weak at
counseling, and that some counselors have behaved unprofessionally, which in one case had
led to divorce. There was a unanimous feeling that if NAPHAM had its own VCT facilities, 
NAPHAM members would not advocate MACRO. However, despite there being a degree of 
dissatisfaction with the unprofessional conduct of some staff at MACRO, most respondents
felt that overall, the MACRO counselors are good, and indicated that they had recommended 
friends and relatives to MACRO. 
20
4.5 Why do fewer women than men use VCT services?
Figure 9 indicates the VCT demand at MACRO by gender from 1992 – 2003.6
Approximately 70% of MACRO clients are male. 
Figure 9
27
VCT Demand at MACRO by Gender
1992-2003
25 27
16
22 23 22 23 25 24 24 27 29
75 73
84
78 77 78 77 75 76 76 73 71
0
10
20
30
40
50
60
70
80
90
92
93
94
95
96
97
98
99
2000
2001
2002
2003
Female
Male
Linear (Female)
Linear (Male)
Respondents identified a number of reasons why fewer women than men use MACRO VCT 
services, including the following: women are very busy in the homes and may not have 
access to bus fare; men/boys come because they usually have unprotected sex; cultural 
factors i.e. women have to seek consent from their husbands before they go for VCT; women 
are more prone to divorce if found HIV positive than men; literacy levels among women are 
lower than men so they may not understand the whole concept of HIV/AIDS and VCT 
services; fear of stigma and discrimination if found positive and breakage of marriages; lack 
of women empowerment to discuss HIV/AIDS openly; women are more likely to undertake 
VCT at health centers which have integrated VCT with other services such as family 
planning and anti-natal clinics as it is easier to maintain anonymity and it is more convenient. 
Findings are presented in figure 10 below:
Figure 10
WHY FEWER WOMEN THAN MEN USE MACRO 
VCT SERVICES
55%
17%
11%
17%
Cultural Factors
Didn't Respond
Don't know
Other Factors**
** 
- Low literacy levels, Fear of stigma & discrimination, Fear to know their status
4.5.1 Attempts to increase the number of women receiving MACRO’s VCT services
MACRO has launched a number of initiatives to increase the number of women using its 
services, including radio advertisements using women voices, and focus group discussions to 
understand the issues surrounding low utilization among women so that messages can be 
 
6 Voluntary Counseling and Testing Best Practices, Malawi AIDS Counseling & Resource Organization, by 
Katawa Msowoya MACRO Blantyre, Updated 23/08/ 2004
21
better targeted (Focus groups have been conducted in churches, mosques, and market places 
among other places). The introduction of outreach VCT services has also proved to be quite 
successful with more women making use of outreach VTC than men. These initiatives seem 
to have made some impact with demand by women rising from 25% in 1999 to 30% in 2003. 
4.6 Do clients referred by MACRO to treatment and support centers actually go to 
these centers for help?
According to respondents, MACRO clients are referred to other service providers for 
appropriate care and support based on specific needs. MACRO also receives referral from 
other organizations. In the period August 2003 to August 2004 MACRO referred 1,932 
clients to other centers, and 519 clients were referred to MACRO from other organizations 
(See Tables 6 and Table 7 below). Referral letters are used. MACRO keeps a directory of 
HIV/AIDS service providers for referral purposes and meetings with stakeholders are 
conducted to understand mutual benefits derived from referrals. Feedback between referral 
centers is however considered to be weak. 
Discussions with senior management at Malanje and Mangochi Hospitals, as well as the 
Regional Coordinator of the National Association of People Living with HIV/AIDS in 
Malawi (NAPHAM) indicate that treatment and support centers do keep referral records, 
however information systems have not been put in place to make this information readily 
accessible. It is thus difficult to ascertain what number of clients referred by MACRO to 
treatment and support centers, actually go to these centers for help. Based on information 
provided by NAPHAM, approximately 70% of NAPHAM’s 260 members come from 
MACRO referrals i.e. 182 members.
Table 6
CLIENTS REFFERED FROM MACRO TO OTHER ORGANIZATIONS
AUGUST 2003 TO AUGUST 2004
Male Female Total
PLWA (NAPHAM) 219 181 400
Hospital/Clinic 303 266 567
Post Test Club 88 59 147
Home Based Care 3 2 5
FP Clinic (BLM) 2 0 2
TB Clinic 1 2 3
MACRO Clinic 458 327 785
PMTCT Centre 3 22 25
Total 1075 857 1932
Table 7
CLIENTS REFFERED BY OTHER ORGANIZATIONS TO MACRO 
AUGUST 2003 TO AUGUST 204
Male Female Total
Clinic/Hosp 139 133 272
Relative 21 17 38
Friend 16 15 31
Other Client 31 15 46
Religious 10 11 21
CBO 7 9 16
NGO 16 23 39
PMCT 36 17 53
Total 279 240 519
22
5.0 CONCLUSIONS AND RECOMMENDATIONS
5.1 Institutional Capacity
5.1.1 Conclusions
Based on the responses from management and staff at both Umoyo Network and MACRO, as 
well as the views expressed by the previous USAID CTO, the overall institutional capacity at 
MACRO has increased since the Umoyo Network grant management and technical assistance 
award in 1999. However, despite the overall improvement in institutional capacity staff 
members at MACRO are less satisfied with the Governing Body, Leadership and Team 
Development and External Relations than they were prior to the Umoyo award. 
5.1.2 Recommendations
ß MACRO and Umoyo should investigate the reasons for the apparent dissatisfaction of 
MACRO staff members with management, with a view to resolving any underlying 
issues. 
ß MACRO should review its relationships with external partners and develop a strategy 
to improve external relations and regional collaboration.
5.2 Quality of VCT Services
5.2.1 Conclusions
Based on the responses from management and staff at both Umoyo Network and MACRO, as 
well as the views expressed by the previous USAID CTO, the overall quality of VCT service 
delivery at MACRO has improved since the Umoyo Network grant management and 
technical assistance award in 1999. However other factors such as the development of rapid 
testing technology and ‘competition’ from VCT centers supported by other organizations are 
also contributing factors. There has also been a significant increase in the demand for VCT at 
MACRO centers since the Umoyo award. Whilst outreach programs, marketing and 
awareness campaigns have contributed towards the increase in demand, the introduction of 
Anti Retroviral Treatment is also seen to be a contributing factor.
 
Despite the overall improvement in the quality of VCT service, Training; and Accessibility 
and Convenience were seen to be relatively weak, and a number of constraints to providing 
VCT services were identified, including the following: fear of testing because of 
discrimination & stigmatization; communities not adequately sensitized and mobilized to 
support VCT and to accepting HIV+ members of the community; insufficient counselors and 
inadequate counseling rooms; concerns about privacy and confidentiality; clients having to 
travel long distances for VCT services; inadequate and inconsistent flow of funds.
5.2.2 Recommendations
ß MACRO should undertake a needs assessment in order to determine training 
requirements. More regular training and refresher courses, as well as supervision,
should be provided in order to ensure that high standards of practice are maintained. 
23
ß In the short term, MACRO should fence the site to improve the level of privacy. 
ß MACRO should intensify its search for more accessible land, and construct larger 
facilities that will accommodate the increasing demand for services, and at same time 
address issues of confidentiality and privacy in the facility design (e.g. a separate 
entrance and exit; appropriate partitioning, fencing, supervised place for children to 
play, etc).
ß MACRO should recruit and train additional counselors and lab technicians in order to 
meet the increasing demand for services; ensure the workload is more manageable; 
reduce burnout and staff turnover; and offer services over lunch hours and early 
evenings.
5.3 Linkage between Capacity Building and Quality and Quantity of Services
5.3.1 Conclusions
Based on the findings, the evaluation team is of the view that there is sufficient evidence to 
conclude that there is a link between the improvement in MACRO services and the increase 
in MACRO capacity brought about through the Umoyo intervention. In particular this is 
demonstrated by the following: (1) the institutional capacity rating for MACRO increased by 
51% from poor to good; the quality of VCT services increased by 64%; from poor to fairly 
good; (3) 80% of respondents indicated that MACRO’s VCT services improved as a result of 
technical assistance, funding and training provided by Umoyo; and (4) the demand for VCT 
services at MACRO increased significantly after 1999, when the Umoyo Cooperative 
Agreement was awarded. 
5.3.2 Recommendations
ß USAID should consider ‘graduating’ MACRO from the Umoyo Network technical 
assistance program and provide direct support to MACRO. 
5.4 Impact on the Lives of Beneficiaries
5.4.1 Conclusions
Beneficiaries are, in general, satisfied with the VCT services provided by MACRO, despite 
concerns raised by some beneficiaries regarding unprofessional behavior on the part of some 
counselors. 
There are a number of autonomous but interrelated HIV support organizations that work 
closely with MACRO. These organizations all compete for limited resources and funding is 
thinly spread. The consequence is that efficiencies and collaboration between these 
organizations in HIV support service delivery is undermined.
5.4.2 Recommendations
ß Complaints raised by MACRO support groups must be addressed to ensure that 
clients are given appropriate counseling and treated as humanly as possible by all 
members of staff from MACRO. Where necessary staff found to abuse clients should 
24
be appropriately disciplined.
ß Umoyo together with MACRO should consider how best to address the spread of 
limited resources across the various HIV support groups, with the idea of 
consolidating the support groups under a single management entity such as MACRO. 
This would rationalize the allocation of scarce resources and provision of support and 
supervision, as well as create a more coherent and integrated VCT and HIV/AIDS 
support system.
5.5 Gender Issues
5.5.1 Conclusions
Fewer women than men use MACRO VCT services largely as a result of gender/cultural 
based issues - such as women having to seek consent from their husbands before they go for 
VCT; and women being more prone to divorce if found HIV positive than men. Women are 
more likely to opt for VCT at integrated health care centers where family planning and anti￾natal clinics are available and/or at out reach sites where it is easier to maintain anonymity 
and it is more convenient. 
5.5.2 Recommendations
ß MACRO should consider the integration of VCT with other health care services 
which will make VCT a more attractive option for women. 
ß MACRO should engage more with men through civic education to combat the poor 
attendance of women at its VCT centers. 
ß MACRO should increase the number of its outreach clinics.
5.6 Referral System
5.6.1 Conclusions
Whilst MACRO and other HIV service providers do maintain referral records, the absence of 
any electronic information system, makes the analysis of information difficult. However, the 
fact that 182 of the 270 NAPHAM members were referred by MACRO does indicate that a 
fair number of clients referred by MACRO to treatment and support centers actually go to 
these centers for help.
5.6.2 Recommendations
ß MACRO should collaborate with partners to develop and implement a more 
integrated, information based referral system. 
25
6.0 ANNEXES
 ANNEX I: SCOPE OF WORK
USAID Project to be Evaluated:
Malawi AIDS Counseling and Resource 
Organization (MACRO) 
Initial and Final Funding Years:
December 2001 to March 2003
Type Evaluation: Final Source and Amount of USAID funding:
$1,043,370
Purpose and Intended Uses of the Evaluation:
The purpose of the evaluation is to determine if institutional capacity building and 
technical support provided by Umoyo Network to MACRO has resulted in a significant 
increase in the quality and availability of voluntary counseling and testing at MACRO 
(VCT) centers. The audiences for the evaluation report are USAID, Umoyo Network, 
National AIDS Council and MACRO. The results will be used to inform the design of a 
follow-on activity. 
Brief Description of Project and it’s Intended Results:
MACRO was established as a local Non Governmental Organization (NGO) in 1995 to 
strengthen and coordinate the VCT initiatives in Malawi. Currently, MACRO operates 
through three stand-alone centers in the cities of Blantyre, Lilongwe and Mzuzu. 
MACRO’s mission is to provide social and psychological support to individuals and 
families in order to reduce the transmission of HIV and impact of HIV/AIDS.
The objectives of the project are:
ß To improve and strengthen VCT services
ß To increases access and demand for effective and ethically sound VCT services
ß To improve and strengthen management of the information systems
ß To improve and strengthen governing structures
ß To enable MACRO to conduct on-site testing services
ß To develop and distribute gender sensitive IEC materials
ß To strengthen networking/collaboration between MACRO and stake holders 
ß To strengthen support systems in the community for HIV/AIDS affected people.
Evaluation Questions:
1. Has the institutional capacity of MACRO changed?
2. Have services provided by the MACRO changed for the better 
(increased/reached more people (access)/improved in quality terms)?
3. Was the change in MACRO services a demonstrable result of a change in 
MACRO’s institutional capacity, i.e., can a link be proven? What 
unintended events have helped or hindered the delivery of quality VCT 
services?
4. Are beneficiary lives better off because of the services MACRO provided, 
i.e., do beneficiaries view the services as being appropriate to/important for 
meeting their needs?
5. Why do fewer women than men use VCT services?
6. Do clients referred by MACRO to treatment and support centers actually 
go to these centers for help?
26
Evaluation Team:
The evaluation team will be composed of at least three individuals including support staff, 
with experience and expertise in the following areas:
- Project Management;
- Voluntary Counseling and Testing (VCT); 
- Systems Strengthening/Institution building
Team Leader/Project Management Specialist: The Team Leader will be responsible for
overseeing the team and ultimately responsible for the submission of the final draft report
to the Mission. S/he will provide team leadership, plan and coordinate meetings and site
visits, and be responsible for payments of local logistical needs and local staff working
with the team. S/he will lead the preparation and presentation of the key evaluation
findings and recommendations to the USAID/Malawi team and other major partners and
will consolidate reports from other evaluation team members and ensure that a draft report
has been left with the Mission on departure. The COP will review project management
issues including funding , oversight, staffing and network issues. 
HIV/AIDS VCT Specialist: The HIV/AIDS VCT Specialist will find out the number of
staff trained, assess their technical competence, and review curriculum. The Specialist
will assess the referral system for both HIV positive and negative client. S/he will review
infection procedures followed at the VCT center. The specialist should assess post
training support and supervision provided by Umoyo Network. Based on the information
learned during the evaluation, make recommendations for improvements in the ways in
which MACRO implements its program. Where appropriate, different options, with their
merits and disadvantages, should be presented.
Systems Strengthening Advisor: The Health Systems Specialist will need to evaluate the 
progress made towards improving the VCT at the center. Key components of systems
strengthening for the VCT focus on staff training, planning, and budget processes, data
and HMIS systems, referral systems, and supervision. S/he should also evaluate the
impact of Umoyo Network supervisory efforts including the introduction of the
supervisory checklist and processes. This Specialist should also be able to review and
evaluate the progress made towards improving the data collection systems. As part of the 
management of a facility, the Specialist should review the progress towards implementing
a Quality Assurance program, including infection prevention efforts which will have been
done in collaboration with the MOH roll out plans. The Specialist should examine
MACRO’s plans for strengthening and expanding its program, evaluate the proposed
approach, and if necessary, make recommendations for improving these plans. S/he
should also study different options which will contribute to sustainability of the services
offered by MACRO and make recommendations in this regard.
Deliverables:
ß Evaluation Plan (methodology for data collection and analysis and GANTT chart 
showing detailed schedule for all steps in the evaluation) – August 18 (Project 
questions and field work week) and August 20, 2004 – oral presentations and 
handouts on approach for answering evaluation questions and GANTT chart.
27
· Draft Evaluation Report – The team shall provide to USAID/Malawi and 
MACRO a complete draft of the report for review and comment. Following 
submission of the draft report, a joint review meeting between the team and 
MACRO will be held to discuss the draft report. October 6, 2004 send the report 
by e-mail to mhageboeck@msi-inc.com; gausik@whoafrica.org; 
jkerley@usaid.gov. Maximum of 20 pages, single spaced, Word Format , Times 
New Roman12 pt, plus annexes.
ß Oral Evaluation Reports (powerpoint or flip charts and handouts– October 18, 
2004
ß Final Evaluation Report – November 11, 2004 or earlier. 
 
Evaluation Schedule: 
Schedule: Fieldwork will take place during week of September 12 to September 19, 2004.
ß Sunday Sept 12: Team meeting. Finalize preparations for evaluation. 
ß Monday Sept 13: Meetings in Blantyre at MACRO and VCT Centre.
ß Tuesday Sept 14/Wednesday Sept 15: Meetings in Blantyre at Umoyo Network 
Headquarters and VCT Centre.
ß Thursday Sept 16: Meeting in Mangochi with Network Association of People Living 
with HIV/AIDS (MANET)
ß Friday Sept 17/Saturday Sept 18: Return to Lilongwe. Data Analysis/Task Allocation 
Logistics:
The evaluation team will be responsible for all off shore and in country logistical support. 
This includes arranging and scheduling meetings, international and in country travel 
(including vehicle requests), hotel bookings, working/office space, computers, country 
clearance, security briefing, printing, and photocopying. The Team leader shall arrange
all field visits, local travel, hotel, and appointments with stakeholders.
Estimated Budget:
A total sum of $7,000.00 is available for this evaluation. An independent government cost 
estimate totaling $7,000.00 is attached.
28
 Independent Government Cost Estimate
 Mid-Term Evaluation of the VCT Program implemented by the Malawi AIDS Counseling and 
 Resource Organization (MACRO)
Rate No. of 
people
No. of Days Total
 I. TRAVEL/PER DIEM
 - Per Diem 
162.00 
4 7 4,536.00 
 - Return Airticket for Systems Strengthening 600 1 600.00 
 Specialist
 - Fuel for local running 1,000.00 
Sub Total Travel/Per Diem 6,136.00 
II. SUPPLIES
Printing and Photocopying paper 400.00 
Sub Total Supplies 400.00 
III. COMMUNICATION
Fax 50.00 
Telephone 100.00 
Email 300.00 
Sub Total Communication 450.00 
TOTAL COSTS 6,986.00 
ROUNDED TO
US$ 
7,000.00 
29
ANNEX II: MACRO EVALUATION QUESTIONNAIRE
DATE: 
NAME OF ORGANISATION: 
RESPONDENT NO:
QUESTION 1
HAS THE INSTITUTIONAL CAPACITY OF THE NGO CHANGED?
(MACRO – Board Management and Staff, UMOYO, CTO & Activity Manager, NAC, other donors if 
possible)
(1) How would you rate MACRO’s institutional competency in the following areas:
COMPETENCY SUB CATEGORY Before UMOYO T/A After UMOYO T/A
Governance · Governing Body
· Mission Statement
· Legal Status
· Constituency
· Leadership
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
Operations and 
Management
· Administration
· Financial Management
· Information Technology
· Facilities, Property and 
Equipment Management
· Planning
· Internal Communications
· Program Development & 
Implementation
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5
Human Resources · Staff roles
· Task management
· Performance Management
· Staff development
· Salary Administration
· Team Development & 
Conflict Resolution
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
Program & Service 
Delivery
· Sectoral Expertise
· Constituency Ownership
· Performance Monitoring 
and Imp act Assessment
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
External Relations & 
Advocacy
· Public Relations
· Regional Collaboration
· Government Collaboration
· Private Sector 
Collaboration
· NGO Collaboration
· Advocacy
· Mobilization of Resources
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5
· 1 2 3 4 5 
· 1 2 3 4 5
· 1 2 3 4 5
(1) indicates a very low level of development (2) a low level of development (3) a fair level of development 
(4) an advanced management system and competency and (5) represents a very advanced management 
system and competency in a particular sub category
30
QUESTION 2
HAVE THE SERVICES PROVIDED BY THE NGO CHANGESDFOR THE BETTER
(MACRO – Board, Management and Staff, UMOYO, CTO & Activity Manager)
(1) In general how would you rate the following services?
SERVICE BEFORE UMOYO T/A AFTER UMOYO T/A
Pretest Counseling 1 2 3 4 5 1 2 3 4 5
Post Test Counseling 1 2 3 4 5 1 2 3 4 5
Ongoing Counseling 1 2 3 4 5 1 2 3 4 5
HIV Testing 1 2 3 4 5 1 2 3 4 5
(1) very poor (5) very good
(2) Do pretest, HIV testing, and post test procedures exist. How would you rate the pre test and post test 
procedures?
PROCEDURE BEFORE UMOYO T/A AFTER UMOYO T/A
Pretest Procedure YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5
HIV Testing Procedure YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5
Post Test Procedure YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5
(1) very poor (5) very good
Please describe :
(3) How would you rate the accessibility and convenience of VCT services 
ACCESSIBILTY & CONVENIENCE BEFORE UMOYO T/A AFTER UMOYO T/A
Hours of operation 1 2 3 4 5 1 2 3 4 5
Service provided early evening YES/NO YES/NO
Service provided lunch hours YES/NO YES/NO
Service provided weekends YES/NO YES/NO
Supervised space for children to play YES/NO YES/NO
Location 1 2 3 4 5 1 2 3 4 5
(1) poor accessibility (5) very good accessibility
Please describe: 
4) How do you rate the level of privacy for counseling sessions?
PRIVACY BEFORE UMOYO T/A AFTER UMOYO T/A
Level of privacy 1 2 3 4 5 1 2 3 4 5
(1) Very little privacy (5) very good privacy 
(5) How do you rate the quality of ventilation in the waiting areas?
WAITING AREA BEFORE UMOYO T/A AFTER UMOYO T/A
Quality of ventilation 1 2 3 4 5 1 2 3 4 5
(1) poor ventilation (5) very good ventilation 
31
(6) Does the centre have a policy on confidentiality? Is this written. How do you rate the adherence to the 
principle of confidentiality?
CONFIDENTIALITY BEFORE UMOYO T/A AFTER UMOYO T/A
Does the centre have policy on 
confidentiality
 YES/NO YES/NO
Is this a written policy YES/NO YES/NO
Level of Confidentiality 1 2 3 4 5 1 2 3 4 5
(1) low level of confidentiality (5) high level of confidentiality 
(7) Have staff received specific guidance about the role of counseling and confidentiality?
CONFIDENTIALITY BEFORE UMOYO T/A AFTER UMOYO T/A
Counselors YES/NO YES/NO
Laboratory staff YES/NO YES/NO
Non counseling medical staff YES/NO YES/NO
Ward attendants YES/NO YES/NO
Receptionists YES/NO YES/NO
Ancillary staff (e.g. cleaners) YES/NO YES/NO
(8) Where do you carry out HIV tests?
HIV TESTING BEFORE UMOYO T/A AFTER UMOYO T/A
All testing on site YES/NO YES/NO
Preliminary testing on site, 
confirmations sent to other 
laboratory
YES/NO YES/NO
All test at carried out in other 
laboratory
YES/NO YES/NO
(9) What is the time interval between taking blood and results being available? 
HIV RESULTS BEFORE UMOYO T/A AFTER UMOYO T/A
Time interval for results
(10) Do you have a quality control system in place for HIV testing? How would you rate the quality 
control system in place for HIV testing.
HIV TESTING QUALITY 
CONTROL 
BEFORE UMOYO T/A AFTER UMOYO T/A
Quality control system in place YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5
(1) very poor (5) very good
Please describe:
(11)Is there a hazardous medical waste management system in place, and are there procedures to protect 
against infection? How would you rate these? 
MEDICAL WASTE BEFORE UMOYO T/A AFTER UMOYO T/A
Medical waste management 
system
YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5
Procedures to protect against
infection
YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5
(1) very poor (5) very good
Please describe:
32
(12) Are any inducement given to people attending the site e.g. transport cost, refreshments
INDUCEMENTS BEFORE UMOYO T/A AFTER UMOYO T/A
Are the inducements YES/NO YES/NO
Refreshments YES/NO YES/NO
Transport cost covered YES/NO YES/NO
Entertainment YES/NO YES/NO
Please describe:
(13) What is the level of service provision and utilization over a twelve -month period?
LEVEL OF UTILIZATION BEFORE UMOYO T/A AFTER UMOYO T/A
How many people have presented 
at the centre
What no. have had pre test 
counseling
What no. have been tested for HIV
What no. have returned for their 
results
What no. have received ongoing
counseling
What no. have been referred to 
other services
(14) What type of training is provided, or that you have received. How would you rate this training? Why
TYPE OF TRAINING BEFORE UMOYO T/A AFTER UMOYO T/A REASON
Pre test counseling YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Post test counseling YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
HIV testing YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
VCT site management YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
VCT supervisor training YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
STI training YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
PMCT training YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Monitoring & Evaluation YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Financial Management YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Finance and USAID Regs YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Strategic Planning YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Infection Prevention YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Stress Management YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Proposal Writing YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
Psycho/Social Positive Living YES/NO 1 2 3 4 5 YES/NO 1 2 3 4 5 
(1) poor training (5) very good training
33
(16) Are there any areas in which you feel you need more training? YES/NO
TYPE OF TRAINING REASON
(17) What support or supervision have you received /or provided. How would you rate the suport and 
supervision received or provided?
SUPERVISION BEFORE UMOYO T/A AFTER UMOYO T/A
Support and supervision 1 2 3 4 5 1 2 3 4 5
Support and supervision 1 2 3 4 5 1 2 3 4 5
(1) very poor (5) very good
Please describe
QUESTION 3 
WAS THE CHANGE IN NGO SERVICE A DEMONSTRABLE RESULT OF A CHANGE IN THAT 
INSTITUTION’S CAPACITY?
WHAT UNINTENDED EVENTS HAVE HELPED OR HINDERED THE DELIVERY OF VCT 
SERVICES?
((MACRO – Board, Management and Staff, UMOYO, CTO & Activity Manager)
(1) Would you say that the quality of service delivery has improved as a direct result of the technical 
assistance and training provided by UMOYO NETWORK to MACRO? Explain. 
(2 ) Do you think there may be other reasons for the improvement in the quality of VCT service delivery? 
Explain.
(3) What do you think may be hindering the delivery of more improved service delivery? 
34
QUESTION 4
CLIENT SATISFACTION
RANDOM SURVEY PRE AND POST UMOYO NETWORK INTERVENION
(1) How did know about the VCT centre that you visited?
Referred (specifically by whom) YES/NO
Recommended to come (e.g. 
partner or friend)
YES/NO
Just dropped in YES/NO
YES/NO
YES/NO
YES/NO
(2) Why did you come to the centre?
(3) How much time did you spend:
Getting your first appointment
Waiting to see your counselor
In the session with your counselor
Waiting to get your HIV results
(4) Did you feel comfortable with your counselor? Describe the good and bad things about him/her.
(5) Was there enough privacy during your counseling?
(6) Do you wish you had a different counselor (different sex, older, younger)?
(7) Were you able to see the same counselor for discussion both before and after the test?
(8) What information did you receive from you counselor?
(9) If a friend or relative were in a similar position to you before you came to the service, would you 
recommend that he/she came to the service. Why?
(10) Have you recommended the service to any one else? (Specify how many people)
QUESTION 5
WHY DO FEWER WOMEN THAN MEN USE MACRO’S VCT SERVICES
(1)According to your knowledge do fewer women than men use MACRO’s VCT services?
(2) What is your understanding as to why fewer women than men use MACRO’s VCT Services?
(3) What attempts if any have been made to increase the number of women receiving MACRO’s VCT 
Services?
35
QUESTION 6
DO CLIENTS REFERRED BY MACRO TO TREATEMENT AND SUPPORT CENTERS ACTUALLY 
GO TO THESE CENTERS FOR HELP
(MACRO management and staff, referral centers)
(1) Describe how the referral system works and any problems and successes
(2) Are there adequate referral services available, particularly for the needs of the people who test 
positive?
(3) Do you receive referrals from any of the following:
REFERRAL CENTRE YES OCCATIONALLY NO
Medical service e.g. hospital or clinic
Social services
Other counseling services
NGO’s
Family planning services
TB/chest clinic
STI services 
Traditional Healer
Spiritual religious groups
Other
(4) Are clients referred to any of the following?
REFERRAL CENTRE YES OCCATIONALLY NO
Medical service e.g. hospital or clinic
Social services
Other counseling services
NGO’s
Family planning services
TB/chest clinic
STI services 
Traditional Healer
Spiritual religious groups
Other
(5) Is there any way of knowing from the referral system in place what number of clients referred by
MAC RO to treatment and support centers actually go to these centers for help?
36
REFERRAL CENTRE NO. CLIENTS REFERRED NO. CLIENTS PRESNTING AT 
REFFERAL CENTRE
Medical service e.g. hospital or clinic
Social services
Other counseling services
NGO’s
Family planning services
TB/chest clinic
STI services 
Traditional Healer
Spiritual religious groups
Other
37
ANNEX III: LIST OF KEY INFORMANTS
1. UMOYO Network:
- Carrie Osborne, Program Manager
- Isaac Chipofya, Finance and Grants Manager
- Amanda Manjolo, Capacity-Building Coordinator
- Jonathan Mbuna, Administration Manager
- Gibson Manda, Monitoring & Evaluation Specialist
- Joyce Wachepa, HIV/AIDS Coordinator
2. MACRO:
- Wellington Limbe, Executive Director
- Katawa Msowoya, Center Manager
- Angela Absent, Administrative Assistant
- Dackson Kampira, Acting Senior Counselor
- Joyce Khomba, Counselor
- Effie Mtwana, Counselor
- Emmanuel Zgambo, Counselor
- Karikurubu Joachim, Lab Technician
- Ian Gadama, Receptionist
3. SUPPORT ORGANIZATION:
- Anthony Chaima, Acting Regional Coordinator, NAPHAM 
- Sawe Kasambwe, Field supervisor, NAPHAM
- Ben Mpulula, Youth Coordinator, Post Test Club
- Chimwemwe Mtawali Youth Ambassador
4. OTHER STAKEHOLDERS:
- Alfred Chirwa, Former MACRO CTO 
- Dr. F. Chimbwandira, District Health Officer, Mulanje
- Linely Chewere, Deputy District Nursing Officer, Mulanje
- M. Saizi, Acting District Health Officer, Mangochi
- Andrew Maluwa, Deputy District HIV/AIDS Coordinator Mangochi
38
ANNEXES IV – VII: DATA TABLES
ANNEX IV: INSTITUTIONAL CAPACITY OF MACRO BEFORE & AFTER 
UMOYO
INSTITUTIONAL CAPACITY BEFORE UMOYO NETWORK
COMPETENCY UMOYO MACRO USAID TOTAL
Governance 2.2 3.5 2.0 2.4
Ops Management 2.0 3.2 2.3 2.5
Human Resources 2.2 2.8 3.0 2.7
Program Delivery 2.2 3.0 2.0 2.2
External Relations 2.0 3.2 2.7 2.6
Overall Institution 
Competency 2.1 3.1 2.5 2.5
INSTITUTIONAL CAPACITY
BEFORE UMOYO NETWORK 
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Governance
Ops Management
Human Resources
Program Delivery
External Relations
Institution Competency
UMOYO
MACRO
USAID 
TOTAL
INSTITUTIONAL CAPACITY AFTER UMOYO NETWORK
COMPETENCY UMOYO MACRO USAID TOTAL
Governance 4.1 3.7 4.0 3.9
Ops Management 3.9 3.9 3.4 3.7
Human Resources 3.8 3.7 3.7 3.7
Program Delivery 4.1 3.9 3.5 3.9
External Relations 3.6 3.9 3.4 3.6
Institution 
Competency 3.8 3.8 3.6 3.8
39
INSTITUTIONAL CAPCITY 
AFTER UMOYO NETWORK
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Governance
Ops Management
Human Resources
Program Delivery
External Relations
Institution Competency
UMOYO
MACRO
USAID 
TOTAL
40
ANNEX V: PERCENTAGE CHANGE OF INSTITUTIONAL CAPACITY
INSTITUTIONAL CAPACITY: PERCENTAGE CHANGE BY ORGANIZATION
% 
CHANGE
% 
CHANGE
% 
CHANGE
% 
CHANGE
UMOYO MACRO USAID TOTAL
SUBCATEGORY
Governance
Governing Body 88 -12 200 54
Mission Statement 78 19 150 69
Legal Status 129 23 100 70
Constituency 70 18 0 109
Leadership 70 -17 33 22
Subtotal 84 6 100 61
Average Score 84 6 100 61
Operations and Management
Administration 60 9 50 35
Financial Management 114 6 50 45
Information Technology 100 73 100 90
Facilities, Property and Equipment Management 100 26 50 54
Planning 88 35 50 53
Internal Communications 75 14 33 35
Program Development & Implementation 129 3 33 40
Subtotal 93 21 50 49
Subtotal Average Score 93 21 50 49
Human Resources
Staff roles 89 75 33 63
Task management 50 41 0 29
Performance Management 63 44 0 32
Staff development 78 36 67 60
Salary Administration 89 12 33 41
Team Development & Conflict Resolution 100 -9 0 17
Subtotal 77 30 22 40
Subtotal Average Score 77 30 22 40
Program & Service Delivery
Sectoral Expertise 80 30 100 66
Constituency Ownership 78 50 0 145
Performance Monitoring and Impact 
Assessment
114 18 50 50
Subtotal 88 31 75 79
Subtotal Average Score 88 31 75 79
External Relations & Advocacy
Public Relations 71 39 0 31
Regional Collaboration 86 9 0 23
Government Collaboration 60 23 0 26
41
Private Sector Collaboration 75 -8 33 27
NGO Collaboration 78 6 33 33
Advocacy 67 51 0 36
Mobilization of Resources 100 44 300 108
Subtotal 75 21 26 37
Subtotal Average Score 75 21 26 37
TOTAL SCORE 83 21 43 747
TOTAL AVERAGE SCORE 83 21 43 51
42
ANNEX VI: QUALITY OF SERVICES BEFORE AND AFTER UMOYO
QUALITY OF SERVICES BEFORE UMOYO
COMPETENCY UMOYO MACRO USAID TOTAL
HIV Testing and Counseling Services 2.3 3.2 2.8
Adherence to HIV Procedures 2.4 3.3 2.0 2.6
Accessibility and Convenience 2.7 3.2 2.0 2.6
Privacy 2.8 3.0 3.0 2.9
Waiting Area 3.0 3.9 1.0 2.6
Confidentiality 3.5 4.8 3.0 3.8
Quality Control 2.3 1.9 1.0 1.7
Waste Disposal & Infection Control 2.0 4.3 1.0 2.4
Training 1.3 2.2 3.5 1.8
Supervision 1.5 2.1 2.0 1.9
Overall Quality of Services 1.9 2.8 1.8 2.2
QUALITY OF SERVICES BEFORE UMOYO
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
HIV Services
HIV Procedures
Accessibilty and Convenience
Privacy
Waiting Area
Confidentiality
Quality Control
Waste Disposal & Infection C...
Training
Supervision
Overall Quality of Services
UMOYO
MACRO
USAID
TOTAL
QUALITY OF SERVICES AFTER UMOYO
COMPETENCY UMOYO MACRO USAID TOTAL
HIV Testing and Counseling Services 3.8 4.2 3.8 3.9
Adherence to HIV Procedures 4.0 4.5 4.3 4.3
Accessibility and Convenience 3.6 3.4 3.5 3.5
Privacy 4.0 3.7 5.0 4.2
Waiting Area 3.8 3.0 3.0 3.7
Confidentiality 4.8 4.8 5.0 4.8
Quality Control 4.0 4.6 3.0 3.9
Waste Disposal & Infection Control 4.0 4.8 3.0 3.9
Training 4.1 2.8 3.5
Supervision 3.5 3.5 5.0 4.0
Overall Quality of Services 4.0 3.2 3.9 3.6
43
QUALITY OF SERVICES AFTER UMOYO
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
HIV Services
HIV Procedures
Accessibilty and Convenience
Privacy
Waiting Area
Confidentiality
Quality Control
Waste Disposal & Infection Con...
Training
Supervision
Overall Quality of Services
UMOYO
MACRO
USAID
TOTAL
44
ANNEX VII: QUALITY OF VCT SERVICES
QUALITY OF VCT SERVICES: PERCENTAGE CHANGE BY ORGANIZATION
% 
CHANGE
% 
CHANGE
% 
CHANGE
% 
CHANGE
UMOYO MACRO USAID TOTAL
TESTING AND COUNSLING
Pretest Counseling 60 44 NIL 48
Post Test Counseling 75 17 NIL 38
Ongoing Counseling 56 -7 NIL 4
HIV Testing 60 65 NIL 71
Subtotal 62 28 NIL 40
Average Score 62 28 NIL 40
PROCEDURES
Pretest Procedure 60 38 100 62
HIV Testing Procedure 60 48 150 79
Post Test Procedure 78 23 100 58
Subtotal 66 35 117 66
Average Score 66 35 117 66
ACCESSIBILTY & CONVENIENCE
Hours of operation 40 7 0 14
Location 26 6 300 60
Subtotal 33 7 75 33
Average Score 33 7 75 33
PRIVACY
Level of privacy 45 22 67 45
Subtotal 45 22 67 45
Average Score 45 22 67 45
WAITING AREA
Quality of ventilation 25 9 200 39
Subtotal 25 9 200 39
Average Score 25 9 200 39
CONFIDENTIALITY
Level of Confidentiality 36 0 67 29
Subtotal 36 0 67 29
Average Score 36 0 67 29
HIV TESTING QUALITY 
CONTROL 
Quality control system in place 71 147 200 123
Subtotal 71 147 200 123
Average Score 71 147 200 123
MEDICAL WASTE 
45
Medical waste management system 100 15 200 64
Procedures to protect against 
infection 100 9 200 60
Subtotal 100 12 200 62
Average Score 100 12 200 62
TYPE OF TRAINING 
Pre test counseling 100 15 NIL 47
Post test counseling 75 20 NIL 41
HIV testing 189 53 NIL 100
VCT site management 189 -10 NIL 52
VCT supervisor training 211 8 NIL 86
STI training 333 50 NIL 159
PMCT training 700 0 NIL 167
Monitoring & Evaluation 133 50 NIL 96
Financial Management 700 10 NIL 132
Finance and USAID Regs 767 25 NIL 164
Strategic Planning 167 7 NIL 70
Infection Prevention 167 42 NIL 95
Stress Management 133 200 NIL 157
Proposal Writing 300 20 NIL 113
Psycho/Social Positive Living 267 55 NIL 129
Subtotal 215 27 NIL 96
Average Score 215 27 NIL 96
SUPERVISION
Support and supervision 133 65 150 113
Subtotal 133 65 150 113
Average Score 133 65 150 113
TOTAL SCORE 111 15 182 69
TOTAL AVERAGE SCORE 111 15 111 64
46