Insight from both service-users and service-providers suggests that, for sensitisation to be • Sensitisation need not only be instructive. The effect is deepened when linked to effective: accountability and engagement: the person-to-person interface between health providers and health service users. Both groups agree that better engagement would lead to improved • The process should engage ALL facility-related personnel, not only clinical staff and relationship and higher quality of service. managers, for at least two reasons: o Support staff (eg. security guards) are often an outsourced service, so are not included in sensitisations. LGBT service-users report that such ‘gatekeeper’ positions – security guards, receptionists, etc. – commonly present attitudes and dispositions that dissuade them from seeking further services. When this happens, clinicians and managers may never know of such incidents; clients may have voluntarily opted out. o Unless sensitivity is distributed across the facility, and consistent – if it is disproportionately concentrated in a small number of individuals – stigma is intensified, trust and confidence of LGBT service-users towards the facility decrease, and utilisation of services decreases. “The whole facility must be sensitive to LGBT people – it has to be a standard practice – not only a few individuals who are trained to deal with us, who then leave when there is staff turnover.” “We already know when we get there, people look at us and call Mavis: ‘Mavis, your people are here for you.’” “I went to the clinic, but Auntie Mavis wasn’t there. So I went home.” “Let’s work together more; we bring in what we have; talk together about what will work best for this community....” (facility manager) “There’s a need for better interaction with clients about their perceptions and expectations.” (facility manager) “People have these attitudes. Maybe we can say they shouldn’t have them because they are health workers, but in reality they still have those attitudes. They don’t have the opportunity to understand the person they’re serving. These are new things for our people. I mean, most people in Zimbabwe have never even heard of a trans person.” (facility manager) “More engagement would help. It would help us. We want to engage with them more, on a personal level and a managerial level. We could arrange a half day or a whole day workshop so we can become more aware of their needs. We want to know them. We want to engage them. Our engagement is not enough. And to get feedback from them if we are not doing enough.” (facility manager) • Processes need to be periodically REPEATED so that longer-serving staff are updated, and newer staff are oriented to the material. In the economic climate of Zimbabwe, health worker turnover is high; consequently, those service-providers who may have participated in an awareness workshop at one time may no longer be working at the facility. For example, GALZ delivered a sensitisation activity at PSI Africa House Harare in early 2017. By October 2017, up to 80% of the facility staff have changed. • Processes aimed at health workers should address more than basic awareness and attitudes, although these remain necessary. Health workers require – and desire -- technical sensitisation as well, to have a better understanding of the clinical dimensions of care for particular groups within the key populations community (STIs; trans-health; women who have sex with women; etc.). A better understanding of the medicine and biology would create greater confidence and competence, and contribute to deepening shifts in attitude, perception and professional practice. PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 17