2. The one quality not named by either service-users or serviceproviders as a standard of a good health service: “ACCOUNTABLE” why it is that particular drugs are routinely unavailable; why seemingly unnecessary contact The set of qualities identified by healthcare-seekers to define a “good health service” is service-users. The situational analysis confirms that, frequently, service-users might feel information is being asked for – but seem not to be explained. iv. Nor is this absence of provider-supplied information met by high levels of enquiry from significant for one other reason – the conspicuous absence of one standard: accountability. uncomfortable, unclear or uneasy about a procedure or exchange at the facility, but seldom If healthcare were a product, a commodity, surely consumers might expect to have some say One reason identified for such reluctance is a low level of health rights literacy and general in the quality of that product? If healthcare were a service, surely users of that service might expect to have some say in how the service is delivered? In both cases, customers might expect to express dissatisfaction should that product or service be unsuitable. Arguably, healthcare is both product and service; and yet no respondents saw it as important that good public health required good public accountability. Perhaps it is unsurprising in the political context of Zimbabwe where citizens are less free to exercise their rights and responsibilities to hold duty-bearers and public institutions answerable to the communities they serve. Still, this omission seems ironic amongst the constituency of a human-rights organisation such as GALZ – that service users might expect to have a right to transparency, inclusion, participation, engagement and answerability – and a telling oversight by service- providers. As discussed later in this report, the absence of accountability – both the expectation of it by service users, and the discipline of it by service providers – is significant to an understanding of the health service experience by Key Populations: ask “why?” or feel confident to refuse or decline. personal health awareness amongst the Key Population constituency, best expressed by one trans woman respondent: “How do we hold people accountable when we ourselves don’t know what to hold them to account about...and when we feel like they’re doing us a favour by even treating us at all?” 3. All health facilities agree that priority “KP-services” are provided to the same defined Key Population client groups...except one: women who have sex with women (WSW). The same three key-populations are unanimously identified as “targets” or “client groups” by facility managers and service-providers in each of the three health facilities: men who have sex with men (MSM); sex workers (SWs) and transgender people (TG). Managers and service-providers, however, are not unanimous in identifying one population as a client group: lesbian and bisexual women, and other women who i. Despite the partnership between GALZ and the three health facilities to provide services to the Key Populations constituency, these populations have never met directly with the service providers to discuss their experiences and expectations. There remain considerably low levels of interpersonal engagement between those entities that might normalise relationship, build trust and openness, and equalise perceived power disparities. ii. Low to no feedback is given to populations on health outcomes, on performance standards, on statistical data. As a result, populations may have curiosity about what happens to all the data collected from them during facility visits, but have no ownership of it, or insight into it. iii. Service-users have low-levels of information about clinical practice or policy-driven motivations that have direct bearing on their experience of care at facilities. Many issues about which service users are dissatisfied are easily explicable by service-providers – eg. why HIV-testing is so strongly encouraged before STI treatment at, particularly, PSI facilities; PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 10