members, unsurprisingly, feel significantly more disenfranchised as stakeholders in the Community members express a sense of frustration and futility, that there may be little point system for health than health providers might assume, with little agency to realistically in exercising accountability, as there is little follow-up or feedback from service providers. exercise accountability. This is not limited to responses to complaint; it also extends to sharing information about statistics, data collected and health outcomes. “If we complain, then we can be told ‘these are the policies of the clinic’. Or ‘these are the policies of the government’”. “The government releases the DHIS reports annually, but the categories are ‘male’, ‘female’, ‘MSM’ and ‘sex worker’. There is no recognition or visibility of trans health in that information “At PSI, there is an “us” and “them”. They gang up to protect each other if you complain. And that is released. But we are also using those facilities.” then what? If you complain, then you must know you still have to come back and deal with that staff member when you want to come and access the service. We don’t have other “Reports come out that cover population information; they are there for national statistics. options if we don’t like this one.” But they are also in technical language that is not accessible to us ordinary people.” “If you complain they say ‘go and complain to the government; we haven’t been paid. We “I’ve only seen evaluations and feedback in hotels. And maybe at some NGO workshops. But are understaffed.’” not for PSI.” “They think they are doing us a favour; they’re not accountable to us. It’s like charity, like “They have a suggestion box like all public institutions. But we don’t know who looks at them, they’re feeding the hungry children.” who tends to complaints, what they do with it.” “There are supposed to be these Health Committees in wards. These are structures that are “You put your complaints, but there’s no feedback. We get told about ‘the situation in the named in a number of documents like the national adolescent SRH strategy and guidelines. country’ or that ‘we are working on it’ or ‘we are rectifying it’, but there’s no feedback on what But these committees are generally not operational. And where they do operate, it’s really is being done or what is supposed to change.” unlikely they will be trans-friendly.” Interestingly, in as much as service providers have become the target for sensitisation by Few opportunities, if any, exist for service users to interact directly with service providers, LGBT health and rights organisations, the constituency of those organisations have a low to face each other to surface concerns, appreciate each other’s perspectives and, through awareness of their rights, and a self-identified deficit of capacity to express their agency in dialogue and joint agreement, resolve conflict. Often, GALZ acts as an intermediary on behalf defence of those rights. of the community to the facility, the benefit of which is questionable. “Our community lacks capacity and awareness and skills to know our rights. To know how “As for PSI (Harare), we can’t approach them directly; we have to go through GALZ. They to report. Or how to challenge. We don’t know the right channels. These people are at the need to engage more with us in the community, not only with their development partners.” clinic; they are trained. I go there with my grievance and they can overrule it with their jargon. “There is a relationship between representatives of GALZ and representatives of the facilities. Like, if I want to complain about that questionnaire they use and how it is offensive or too But we don’t have an opportunity to engage with the providers directly.” personal, they will explain to me why it has to be like that.” “We never get to confront the service providers ourselves. It’s not the first time we talk about “We don’t question even if we are violated. We think they are doing us a favour and we must these issues. We don’t have a say. We feel like a project.” be grateful, even if we are treated badly.” PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 39