for clients referred through a GALZ peer counsellor, KP-respondents speak repeatedly about within the GALZ membership are not recognised by the clinic when they present (eg. lesbians the $1 fee they are required to pay, with or without a coupon. This issue surfaces so frequently or bisexual women) with a coupon, or perhaps do not present with a coupon by choice so as during the Situational Analysis amongst so many different respondents in different groups not to be identified, and subsequently are not afforded the free service. It may well be that from different cities, that it is impossible to believe the experience is isolated, misunderstood receptionists are not uniformly informed about the policy to waive service-fees for referred or misrepresented. KPs, and that these incidents never reach the attention of facility managers or clinical staff who operate under the assumption that no GALZ referral pays for services. “They say services are free, and drugs are free. But the clinics charge us a $1 “handling Three other interrelated issues surfaced during the analysis of affordability that are more fee”. Without paying that fee we can’t access our “free treatment”. And we still have to get broadly discussed under other sections of this report: transport there and back.” 1. An over-burdened health facility increases waiting time for clients with at least two effects: “The dollar sounds so little, but when you add transport and medication – especially if you increased visibility and exposure, and time lost for generating income. As one respondent have to get medicines from a pharmacy with a prescription – you need about $5 or $6.” reflects: “Transport costs money. And being at the clinic all day takes time when people could be earning money.” “You come and pay at reception before you get the services. And if you don’t have that dollar – if I don’t have that dollar – I will die. They will turn you away. And that’s life threatening if 2. The perception of affordability is generally much higher for gay and bisexual men, and you don’t get some drugs like ARVs. And they want that dollar to give you a 3-month supply. for transwomen (who often present at facilities as men in order to be less visible) than for If they don’t get that dollar you can’t access drugs or services.” lesbian and bisexual women. The gender-advantage for men is repeatedly made visible. Perhaps this is because men are more vocal, more likely to complain. Perhaps it is because “When we as peer counsellors give our clients a coupon, they’re not supposed to pay. But of the public-health/HIV-emphasis on reaching “MSM” that gay men’s access to services – some are paying even with the coupon.” including affordability – is more deliberately facilitated by the health service. And by their own admission, lesbian women are more reluctant to be visibly identifiable, conscious of “We come with the coupon, but they tell us ‘...never mind that coupon...$1.’” being stigmatised. “At PSI, you get CD4 testing for $1. But you have to wake up and be there very early. If you “The services are affordable, yes! But for who? For MSMs. They access everything, we get there late, they don’t do anything for latecomers. They only take 8-10 people per day. At assume.” (LB woman, Bulawayo) Wilkins, they do 100 people on Tuesdays only. You can get there at 4AM and stay until 4PM.” “That coupon stigmatises us. As soon as they see that coupon, they know these ones are “If you get a coupon from GALZ and a Peer Educator, you don’t pay. But without that coupon, from GALZ and they are KP.” (LB woman, Harare) it’s a dollar for the service. And without that dollar, there’s no service.” 3. Whilst HIV-negative clients who are exposed to reasonable risk are encouraged to initiate “If you don’t have money, they don’t treat you; if there’s an emergency, you’re told to go to the PREP at no cost, post exposure prophylaxis (PEP) is complicated and expensive to access, police to get an affidavit stating that you can’t pay and why.” but often felt to be necessary for members of key populations. The issue of payment for services is sensitive and contentious, with several contrasting “If you go for PEP, they say ‘we don’t have’. There’s a long process to get it and it’s not easy. narratives that may only be reconciled and resolved through engagement and dialogue There’s a preference for rape victims – and the assumption is that men can’t be raped, so you between health facility staff and community members. It may be that certain constituencies can’t report that as a gay man, or as a trans woman. And to get it from a pharmacy is $54.” PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 30