Affordability Wilkins and PSI are three select facilities, unlike most in the public health system, where members of key populations can access services in a comparably safe environment. This Wilkins HRE GBT 10 LBT 3 TW 7 Facility 10 PSI HRE GBT 4 LBT 3 TW 7 Facility 10 PSI BYO GBT 9 LBT 1 TW 5 Facility 10 Health Facilities are unanimous. Services are affordable in that they are offered free. Unlike Wilkins, PSI is ordinarily not a free service – clients typically pay a $1 (USD) administration fee – but key population clients who are referred through GALZ are exempted from paying through a coupon system. Medication is supplied at no cost to key population clients and, even without the coupon, clients receive the services they need should they be unable to pay for them. Community members agree that the health facilities are significantly more affordable than other options that are otherwise inaccessible to most. “Services are affordable compared to consultations at a private clinic where it’s anywhere from $10 to $50.” means, however, that those essential services are not available to community members in close proximity to their homes. Travel is necessary to reach the facilities; and travel has significant implications for affordability in both Harare and Bulawayo. “At Wilkins, you never have to pay, the service is free; but the challenge is when you don’t have transport money to get there.” “In Zimbabwe, most people live on less than $1 per day. 85% of people are unemployed. And amongst some of us who are gay or trans, we have even less employment. Most of us will need to take two kombis to get to Wilkins from where we live. That’s already $2 just for transport one way. And $2 back.” “People who need the services can’t afford to live in that area where the clinics are. So they have to have transport to get there. And transport costs money.” “To get to Wilkins, it needs two vehicles, and the transport cost that comes with that.” “Compared to other places where services cost $5 to $10, the services are affordable. You can get testing, treatment, counselling and medication for $1.” For service-users, however, the analysis of affordability is not as simple. It is a more complicated issue – not only about the direct cost of specific services – described by KPrespondents through a systems-approach that bridges questions of affordability into issues of accessibility and, more broadly, social and economic justice, and livelihoods. “Most LGBT people don’t go to work. They are marginalised in this country. We live in ghettos. Services at a facility might be free, but health is not affordable.” “Services are free. And sometimes even medication is free. But medications need food and “Transport costs you $1, and then you have to be there all day.” “We are told that PSI will give you $2 for transport money. It happened the first time I went that I asked about it, and was told ‘There is no money’”. For trans people, using public transport to reach the health facility is not only an issue of money; it’s also an issue of visibility. And with visibility come stigma and harassment. “If I needed to go to PSI with public transport, I’d never go.” “That is why the trans community is dying.” During the Situational Analysis exercise, two trans women shared their traumatic experience nutrition. People need to be able to eat to take the medications.” of harassment in Harare when their car was surrounded by a mob of some forty men, who “Prep is free, so that’s very affordable. But you need to eat to be on PREP, and that’s why I to drive away. pulled out of PREP.” climbed over the vehicle, shook it violently, and tried to pull them out before they were able In as much as health facilities claim that a free service is made available to key populations, and that a coupon system provides for a waiving of PSI’s service fee PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 29