Accountability possibility.” (PSI-H) “Clients have a right to see the management and report any unsatisfactory incidents.” (PSI-B) Wilkins HRE GBT 9 LBT 1 TW 7 Facility 7 PSI HRE GBT 2 LBT 1 TW 7 Facility 10 accountability – complaints boxes, suggestions boxes, PSI has a system that makes it PSI BYO GBT 8 LBT 1 TW 5 Facility 9 possible to identify which service provider interacted with a client who may complain Of the many standards that might constitute good health services, “accountability” – the idea that healthcare providers could be held answerable for the quality of care and overall user-experience; or that service-users should have access to information collected about them – was the least developed in the minds of respondents during the Situational Analysis, whether service provider or LGBT service user. Accountability as a standard and value in health service provision may be one of the more significant, albeit subtle, metrics for effective, efficient, acceptable programming to Key Populations within a healthy system for health: it becomes a measure of conversation and dialogue between providers and users; it speaks to the rights of users to access to information, to informed consent, to autonomy that is governed by their ability to make informed choices about what is good for them, to dignity because they are recognised as stakeholders with equity in the system; it indicates the level of community engagement and ownership within the health system – both necessary to reconcile and integrate health systems strengthening and community systems strengthening into a responsive system for health. Accountability, responsibly exercised, and non-defensively received, makes systems better. It increases trust, relationship, human agency and voice and applies them to quality assurance. It becomes obvious how this effect is desirable and effective to increase access and uptake of services by Key Populations. Achieving these gains with those populations holds benefit for all users of the system, irrespective of sexuality or gender. Health care providers agree that accountability is important, and implicit for professional staff in that sector. “We are professionals who have taken an oath, and the Patient Charter is always applicable. Whoever offers a service is accountable.” (PSI-H) “We have standard operating procedures and protocols and templates to exhaust every PERCEPTIONS, PERSPECTIVES Health facilities confirm that certain institutional mechanisms are in place to invite about a negative experience after the fact – although it is acknowledged that these are not actively promoted or effectively utilised. Users who may benefit from such structures are not sufficiently informed of how to access those mechanisms. Nor is there sufficient interaction between health staff and communities to encourage that kind of exchange and signal it is safe. “At Wilkins, we have a complaints and compliments box. We do monthly reviews amongst the staff where we talk about any incidents. We have occasional exit interviews to check client satisfaction. And we maintain an open-door policy for feedback. We’ve had three meetings recently with GALZ, community representatives and Wilkins management which is a good sign. But still there are gaps and little interaction, so accountability is not routine or systematic.” “We [PSI-B] have suggestion boxes for concerns in two locations around the facility, although...who opens that box? And is there a report back to the community? Are people informed of the mechanisms? Only if they ask about it.” It is interesting to note that, with reference to Wilkins and PSI in Bulawayo, gay and bisexual men have had positive experiences with feedback to health providers: “At Wilkins, we had issues with them about long wait time and we complained. They actually called us in to explain, and to try and understand our experience and how best they could improve their services. They invited feedback from the community. They have an open-door policy to see the director, and to report any bad experiences with staff.” “These guys at the facility are still growing and we’re creating a relationship with them. But they do come back to us and ask if we are satisfied. They try to understand us.” These experiences are encouraging and demonstrate that accountability is possible. That perspective, however, is not consistent, nor is it universal across the populations. Community Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 38