might wish to remain as discrete and anonymous as possible; placing the burden on this man?”. population to ‘out itself’ to justify access to decent, equitable care seems unreasonable and unethical; a health system that behaves as though the population does not exist and does not know what to do with them or how to serve their unique health needs does not strongly incentivize the population to become visible. • In the data-collection systems of these health facilities, no provision is made to capture lesbian or bisexual women who may be referred for services. They are instead captured as ‘sex workers’. The data-collection tools that are consistent with the District Health Information System (DHIS) recognise “MSM” and “Sex Workers”. Even within the LGBT community, patriarchy subsists, making available better care to those who are men, or who have sex with men, a bias that is consistently evident in the perceptions of different populations towards the availability, accessibility, affordability and acceptability of health services within the same facilities. ‘How do people feel welcomed and included when they do not see themselves represented in a space?” In the unique ecology of institutional health service provision to key populations in Zimbabwe, both sides – service providers and service users – have a steep gradient to overcome to reasonably reconcile their respective expectations, obligations and aspirations, but engaging openly with each other to surface and express those expectations will have a considerable levelling effect. 5. Consistently low availability of a limited set of high-demand services is sufficient to significantly compromise accessibility, utilisation and uptake of many other services available to Key Populations at health facilities. If the Situational Analysis reveals these varied levels of experience between the Key Populations groups, it also shows a vast difference in perception between the service- In a context where social norms, political positions and legal provisions malign and criminalise providers and the groups they serve. Consistently, service-providers assume their services to members of key populations, such groups – men who have sex with men, women who have Key Populations are considerably better received than is reflected in the experience of their sex with women, trans people – become isolated and reluctant to seek care and services, clients. fearful of harassment, stigma, discrimination, persecution that may come with exposure in public facilities. These conditions only increase the vulnerability of already vulnerable This discrepancy can be attributed to a number of reasons discussed throughout this report, populations whose access and uptake of essential services are limited by structural and but including: institutional barriers. • KP clients perceive that service-providers have an inadequate clinical knowledge of their specific sexual or reproductive health needs (eg. trans health; hormone interaction; the Against this backdrop, the services made available through the partnerships with PSI in health risks associated with breast binding; anal health; STIs that may present in the anus Bulawayo and Harare, and with Wilkins Hospital in Harare offer key populations access to a or throat; STIs and other physiological conditions that may present in women who have sex range of interconnected services that are unlikely to be accessed elsewhere: HIV counselling with women) and are ill-equipped to give appropriate health advice. and testing; STI treatment; access to PREP; enrolment on ART; family planning; cervical • Service providers and facilities perpetuate a heteronormative, cis- gendered environment. cancer screening; TB-screening and treatment; management of chronic, non-communicable While it is recognised that there are serious socio-political challenges that make it difficult for conditions. providers to publicly demonstrate their commitment to care for key populations, no materials or publications in the facility provide health information in a way that represents individuals But, the potential benefits and impact of this comprehensive set of services and interventions or relationships other than traditional heterosexual realities. Questionnaires and protocols are not realised, owing to consistently low availability of a small number of high-demand designed to guide health workers through taking a clinical history presume heterosexual services. The absence of this small set of services has a relationships: “Are you sexually active?”; “If yes, when was the last time you had sex with a PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 12