賦予人們改變的力量
在肯亞，許多資源不足社群／社區在爭取健康平等時，面臨許多相互關聯的障礙和挑戰。Making More Health透過強大的合作夥伴網絡，賦予在地社區改變的力量，推動永續且具有影響力的系統性變革。
當太陽在肯亞魯辛加島的天際線下沉，白鷺鷥在薄暮中優雅地飛翔，一群小船從維多利亞湖（Lake Victoria）的岸邊啟航，為當地社區提供魚類。然而，這美景背後卻隱藏著霍馬灣郡（Homaba）居民所面臨的諸多挑戰。在水面下，環境污染正在對魚類資源造成損害，同時氣候變遷也對其造成負面影響。漁民們不得不為越來越少的漁獲付出更長時間和更多精力，讓他們承受巨大的身心壓力。岸上的女性需要照顧自己和家人，往往在經濟上依賴這些漁民。這可能導致如「以性換魚」等剝削行為，進而使人類免疫缺乏病毒/後天免疫缺乏症候群（HIV/AIDS）等疾病在該島上蔓延，影響當地社區的健康。
相互關聯的問題需要全面的解決方案
這個範例清楚呈現，非洲地區的環境、經濟、社會和健康議題相互關聯，反映了全球許多資源不足社群／社區所面臨的挑戰。在這樣複雜的情境中，僅針對其中一個方向尋找解決方案難以對當地居民生活產生長遠且積極的影響，因此需要更全面的解決方案。百靈佳殷格翰和MMH倡議活動採用生態系統方法的原因就在於此。我們著重從整體上解決與健康有關、相互關聯的問題，包括基礎設施、經濟發展、教育和文化等。我們意識到，許多並存的因素相互作用，進而影響人們的健康狀況。我們的最終目標是幫助醫療服務不足的社區自主實現健康平等。
 以性換魚維多利亞湖畔的社區仰賴淡水魚作為銷售及食用的重要資源。這些資源的捕撈工作主要由男性（漁民）負責，貿易和加工則主要由女性從事。在這樣的經濟體系中，出現了「以性換魚」（或「以魚換性」）的現象。男性漁民和女性魚販之間常存在剝削性的性關係，後者只能透過此方式獲得魚類，以確保她們自己和家人的生計。這種做法導致湖畔社區漁民中人類免疫缺乏病毒/後天免疫缺乏症候群（HIV/AIDS）的高發病率。女性和兒童（無論男女）為了獲得魚而被迫發生性行為，增加他們感染和傳播人類免疫缺乏病毒/後天免疫缺乏症候群（HIV/AIDS）的風險。以性換魚可能持續形成一個依賴、剝削和健康風險的循環，進而影響整個社區。 |
帶動社區進行系統性變革
MMH透過與NGO、社會企業、大學和企業合作，致力於賦予肯亞社區發揮完整健康潛力的能力。成功的關鍵是與當地社區持續對話，並將當地居民的知識和觀點融入解決方案中，進而發展出主動參與的理念和倡議。透過強調合作和共創思維，社區活化的力量可以激勵相關人員，產生正面的影響。
肯亞系統變革者網絡計畫（SCN Kenya）專注於建立和改變整個生態系統，而非僅僅創造單一問題的解決方案，有助於擴大對社區的正面永續影響。
WaWa Kenya—身具使命的NGO
自2020年起，MMH與霍馬灣郡（Homabay）的非政府組織WaWa Kenya合作，攜手致力於推動社區變革。WaWa Kenya的稱名稱源自於史瓦希利語（Swahili），意思是漁婦（Wanawake Wavuvi）。WaWa的故事始於創辦人Cavin Odera的親身經歷。在他12歲時，雙親因人類免疫缺乏病毒/後天免疫缺乏症候群（HIV/AIDS）而雙亡。他的母親曾是一名魚販，為了維持家計不得不「以性換魚」而染病。Cavin Odera回憶道：「那是我一生中最黑暗的時刻；但也是這個過去，激勵了我成立 WaWa，協助賦權給婦女和女童們，和她們一起，共同為社區注入力量」
那是我一生中最黑暗的時刻；但也是這個過去，激勵了我成立 WaWa，協助賦權給婦女和女童們，和她們一起，共同為社區注入力量。
女力覺醒，社區增能
WaWa Kenya的標誌是一名肯亞女性自豪地站在漁船的船首，拋出一張多股線漁網，漁網的邊界描繪出維多利亞湖的輪廓。WaWa的賦權方式，是透過人們自發性的行動帶動社區發展。 WaWa的目標是賦予婦女和女童們謀生的能力，包含學習漁業和農業相關知識、編織和鉤織技術、製作肥皂和洗滌劑、時裝設計、木工、Table Banking(社區微型金融計畫)等關鍵技能，以加強她們的經濟實力。WaWa也在婦女和青年領導者培訓、以及性健康和生殖健康權利領域提供社區支持。
性別平等計畫
Cavin Odera回憶：「起初成立WaWa時，我們認為目標就是賦予女性經濟權力，但當我們開始實際推動時，發現『健康』也是需要談論的議題—畢竟健康與財富相輔相成。」She4Him和 He4Her是隨後由WaWa與MMH共同啟動的計畫，男女共同參與。這個計畫將男性和女性視為一個相互聯繫的系統，而非獨立參與者。 Cavin補充：「僅針對女性或男性的訓練計畫是不夠的。我們需要著重能夠促進性別平等的計畫。」這些工作坊旨在提高對男性健康問題的認識，包括吸毒和酗酒、大男人主義以及心理健康等，這些問題也會影響女性健康。
給予在高壓處境下的男性支持
男性的心理健康狀態是漁業社區中常被忽視的議題。氣候變遷的影響加劇了漁民長時間獨自在水上工作的壓力。不可預測的天氣令漁民很難如期完成目標，更強烈和頻繁的風暴干擾了捕魚活動，同時威脅到人身安全。極端天氣事件可能會破壞漁船、漁網、引擎和存儲設備等漁業基礎設施。
這可能會導致捕魚機會減少、收入不穩定以及食品安全問題，對漁民和整個社區產生影響。為了創造社區永續變革，有必要緩解這些問題對漁民心理健康的影響。
僅針對單一性別的培訓無法有效解決問題，我們需要關注有助於改善性別關係的計畫。
執行方法
沒有任何單一的介入措施或組織能夠解決當今弱勢社區面臨的複雜挑戰。我們的目標是透過聯結不同夥伴，包括社區領袖、非政府組織、社會企業家等，共同促進創新解決方案。同時，支持社區與其他社區之間的平等交流，與其他社區分享知識。我們的使命是以「變革工程師」的身份，促進社區與合作夥伴之間的連結，實現更具永續性的解決方案。
年輕人是改變的動力
Cavin Odera強調：「僅推動反毒活動絕對不夠。我們需要了解男性行為的根本原因，並為他們提供更多替代方案，使他們有更多選擇。」事實證明，He4She和She4Him計畫廣受歡迎，尤其在年輕人之中；他們以能夠與WaWa和MMH產生關聯而感到自豪。這些年輕人們跟同儕分享所學，資訊也在社區中傳播給更多人，逐漸引發態度和行為上的轉變。Cavin Odera表示：「只有團結起來，年輕一代才能更好地彼此照顧，同時關心他們生活的環境。MMH計畫的合作以及共同創造解決方案的行動措施，有助於建立信任，並產生對外擴散的綜效。」
社區活絡帶動居民投入自助行動
Rusinga自助團體是其中一個讓人印象深刻的傑出案例，由大約30個漁民家庭組成。這個充滿活力和奉獻精神的團隊在 He4She和She4Him培訓計畫後成立，致力於在他們的村莊和生活中創造永續性的變革。參加心理健康課程讓他們意識到變革的可能性，開始為自己發聲和採取行動。小組團體會定期開會，尋找提供經濟穩定性的替代收入來源，包含漁業、豬和家禽養殖、造船和微型企業。
他們參加了MMH提供的所有培訓課程，包括商業和數位技能、健康和衛生、節水和文化意識等。透過結合和實施這些解決方案，社區能深刻地改變人們的生活。
 健康平等指的是確保所有個體都有同等機會實現最佳健康結果的原則。這個概念已經超越了對醫療服務的平等接觸，它承認人們基於其經濟、社會和環境背景擁有不同的需求。它承認由於系統性和結構性因素，如貧窮、資源和機會的不平等，以及氣候變遷和環境惡化等，導致了健康差距的存在。它也承認，特定人口，如種族和少數民族群體、低收入戶和資源不足社群／社區，可能面臨更高的障礙，阻礙他們獲得良好健康。這些障礙可能包括難以獲得高品質的醫療保健服務，缺乏經濟機會，教育普及率低，以及缺乏健康知識等問題。 健康平等倡議活動旨在積極消除健康差距，解決體制性的不平等問題。這需要多方面的作法：首先，必須提供可取得並且可負擔的醫療服務，特別是針對資源不足社群／社區；第二，解決嚴重影響健康結果的社會因素，如：貧窮、教育和就業；第三，辨識並解決醫療系統中會導致健康差異的偏見。健康公平的議題至關重要，因為它促進社會正義、維護人權、改善健康、提升經濟效益，並且增強公共健康和福祉。實現健康公平需要所有利益關係方共同協作，讓每個人無論背景或環境，都有機會擁有健康生活。 |
製皂促進健康與經濟自主
WaWa和MMH共同發起的數個計畫進一步說明了健康、衛生和經濟安全問題之間的關聯性。其中一個計畫是製皂，該計畫訓練婦女和女童們製造沐浴、洗衣和保持個人衛生所需的清潔用品。Cavin Odera表示：「這個計畫讓肥皂在社區普及。」這不僅可以改善衛生狀況，還直接影響了女性的健康。製皂也為她們提供了獨立的替代收入來源，因此降低她們面對剝削行為及有害權力動態的脆弱性，同時減少對漁民的依賴。
藉由實際支持建立信任
生活在維多利亞湖畔的女性與女孩有另一個收入來源是自製衛生套裝。套裝中的棉墊和肥皂部分由WaWa生產，可以在社區內販售。推動這個計畫的動能也來自於社區本身。 Cavin Odera解釋：「我們決定為婦女和女童們提供更多生活技能和生殖健康課程。」WaWa因此成立了女孩俱樂部，教導年輕女性認識月經、性和懷孕等議題。在課程推動期間，他們發現月經衛生是一個更大的問題。MMH團隊在促進性別教育認知以及衛生套裝生產方面，提供很多支持。MMH社區工作的全球負責人Manuela Pastore表示：「像這樣的計畫提供具體的支持，並在社區中建立了信任感。」
滿足社區個別需求
觀察在Rusinga推動的計畫，我們可以清楚地看到人類健康、經濟穩定與動物健康息息相關。在與當地漁業社區的交流中，他們反覆聽到類似問題：為什麼我們總是遭遇流行病，影響我們MMH 的Bag2TheFuture競賽？該競賽鼓勵百靈佳殷格翰員工參與不同的社會企業計畫。
解決社會結構問題，邁向永續變革
隨著維多利亞湖畔越來越多婦女和女童獲得更多經濟自主權，她們成為所處體系更深層次變革的體現。然而，她們只是變革過程中的一部分。MMH與其合作夥伴正努力從多方面應對生態系統中複雜且相互關聯的挑戰。同時，他們細心傾聽資源不足社群／社區的聲音，並與他們合作，提升他們的能力。在得到伴侶和家庭的支持下，這些堅強的女性成為了弱勢社群永續變革的關鍵推動者。
「加入WaWa之前，我遇到了麻煩：如果找不到發生性關係的人，就無法從湖中得到魚獲。WaWa幫助我貸款，現在我擁有自己的錢，我自由了。我目前是WaWa的副秘書長，我們是一個團體。如果能繼續參與WaWa的活動，相信我的生活會有很大的改善。」
資源不足社群／社區的定義是？
「居住在不平等的環境中的人和動物，在取得醫療保健上，面臨顯著的障礙」。
百靈佳殷格翰對「資源不足社群／社區」的精簡定義，有助於更深入地了解他們所面臨的障礙、實際需求，以及計畫如何提供最具影響力和永續性的解決方案。
根據我們的定義，資源不足社群／社區會在以下關鍵領域遭遇障礙：
EMPOWERING PEOPLE ON THE PATH TO CHANGE
Underserved communities in Kenya face many interconnected barriers and challenges when it comes to health equity. Together with a strong network of partners, Making More Health is empowering local communities to create systemic change that will have a sustainable impact.
When the sun sets over Rusinga Island and the Great Egrets sail majestically through the dusk, a fleet of small boats sets off from the shores of Lake Victoria to provide fish for the local community. But behind this romantic-looking exterior, Kenyans in Homabay County face many challenges which are not immediately visible to the eye. Beneath the water’s surface, environmental pollution is taking a toll on fish stocks which are also being negatively impacted by climate change. As a result, the fishermen piloting their boats have to work longer and harder for shrinking catches, putting them under significant physical and mental strain. Women on the shore who need to care for themselves and their families are often economically dependent on these fishermen. This can lead to exploitative practices such as “sex-for-fish” which have impacted the health of local communities through high rates of HIV/ AIDS and other diseases.
Interlinked issues need holistic solutions
As this example shows, various environmental, economic, social, and health issues are interlinked in this region of Africa, mirroring the challenges of many underserved communities around the world. Creating a long-lasting and positive impact for the people living in these communities is not achieved by finding a solution to just one aspect within this complex web. A more holistic approach is needed. That is why Boehringer Ingelheim and our Making More Health initiative implement an ecosystem approach in our work. We focus on the bigger picture by addressing interdependent issues relating to health, i.e. infrastructure, economic development, as well as education and culture. We recognize that many concurrent factors interact with one another, thereby creating unequal health outcomes across different populations. The ultimate goal is to help underserved communities help themselves on their journey towards health equity.
SEX-FOR-FISHMarginalized communities along Lake Victoria depend on its freshwater fish as a crucial resource to sell or eat. This resource is harvested mostly by (fisher) men, whereas fish traders and processors are predominantly women. Some of these communities engage in what is known colloquially as ‘sex-for-fish’ (or ‘fish-for-sex’). These often exploitative sexual relationships between fishermen and female fish traders enable the latter to gain access to fish, thus ensuring their own survival and that of their families. The practice contributes to the high incidence of HIV/AIDS prevalent among fisherfolk in lakeside communities. Women and children (girls and boys) exposed to sex-for-fish run a particularly high risk of HIV/AIDS acquisition and transmission. Sex-for-fish can thus perpetuate a cycle of dependency, exploitation, and health risks which impacts entire communities. |
Activating communities for systemic change
By partnering with non-governmental organizations (NGO), social enterprises, universities and companies, Making More Health is working to empower communities in Kenya so that they can achieve their full health potential. An essential component for success is the ongoing dialogue with local communities, since this allows Kenyans to incorporate their knowledge and perspectives into the solutions – and develop the ideas and initiative to become active themselves. By putting the emphasis on collaboration and the co-creative generation of ideas, this kind of community activation can increase the positive impact of the measures on the people involved.
System changer networks like SCN Kenya – which focus on building and changing entire ecosystems, instead of just creating solutions to individual problems – can scale up the positive sustainable impact in the communities.
WaWa Kenya: An NGO with a mission
Since 2020, MMH has been collaborating with an NGO in Homabay that works at the community level to actively empower change – WaWa Kenya. The organization’s name comes from the Swahili word for fisherwomen, Wanawake Wavuvi. The story of WaWa begins with its founder Cavin Odera, who lost both his parents to HIV/AIDS when he was only 12 years old. His mother had been a fishmonger and contracted the disease after engaging in the practice known as ‘sex-for-fish’ to gain access to these fish, in order to provide for the family. “That was the darkest moment of my life,” Cavin Odera remembers, “and later it motivated me to establish WaWa to help empower women and girls – and with them the community at large.”
“THAT WAS THE DARKEST MOMENT OF MY LIFE AND LATER IT MOTIVATED ME TO ESTABLISH WAWA TO HELP EMPOWER WOMEN AND GIRLS – AND WITH THEM THE COMMUNITY AT LARGE.
Empowering women and girls – and their communities
The WaWa Kenya logo depicts a Kenyan woman standing proudly in the bow of a fishing boat, casting a many-stranded net which encompasses a silhouette of Lake Victoria. This is an organization that is about people becoming active for themselves, and then empowering activists to reach out into their respective communities. One of WaWa’s goals is to strengthen the economic power of women and girls by giving them the capabilities to earn their own living. This includes training them in key skills such as fishing and farming, weaving and crocheting, soap and detergent making, fashion design, carpentry, and table banking. WaWa also supports communities in the fields of leadership and governance for women and youth, as well as sexual and reproductive health rights.
Programs for both genders strengthen equality
“When we started WaWa, we thought it was all about economic empowerment for women,” Cavin Odera remembers. “But when we got on the ground, we found there was also a need to talk about health – because health and wealth go hand in hand.” She4Him and He4Her are subsequently projects that WaWa co-created with MMH and in which men and women participate together. Both genders are seen as a connected system, not just as individual players, as Cavin Odera explains: “Training programs for women or men only? That’s not really useful. We need to focus on programs that help improve the relationships among the genders.” The sessions focus on raising awareness for men’s health issues which also impact women’s health, including drug and alcohol use, toxic masculinity, and mental health.
Supporting men in an environment under stress
Men’s mental health is a key and often overlooked aspect in fishing communities. The stress of long days and nights alone on the water is being compounded by the effects of climate change. Unpredictable weather makes it difficult for fishermen to plan their trips. Stronger and more frequent storms disrupt fishing and pose risks to the men’s personal safety. Extreme weather events can damage fishing infrastructure such as boats, nets, engines, and storage facilities.
“TRAINING PROGRAMS FOR WOMEN OR MEN ONLY? THAT’S NOT REALLY USEFUL. WE NEED TO FOCUS ON PROGRAMS THAT HELP IMPROVE THE RELATIONSHIPS AMONG THE GENDERS.”
This can lead to reduced fishing opportunities, income instability and food insecurity which impact not just the fishermen, but the entire community. Mitigating these effects on the mental health of fishermen is another component that needs to be tackled to create sustainable change.
OUR APPROACH
No single intervention, nor one organization can resolve the complex challenges vulnerable communities face today. Our goal is to foster the development of innovative solutions, by connecting differentpartners, such as community leaders, NGOs, social entrepreneurs, etc. At the same time, we support these communities, to share their knowledge with other communities, based on a peer-to-peer exchange. Our mission is to act as “change engineers”: connecting communities with partners to enable more sustainable solutions.
Young people are the motors of change
“It’s not enough to do anti-drug campaigns,” Cavin Odera emphasizes. “We need to understand the roots of men’s behavior and offer them alternatives – so that they have a choice.” The He4She and She4Him programs have proven to be very popular, especially among younger people who are proud to be associated with WaWa and Making More Health. By spreading what they are learning among their peers, the messages are reaching ever more people in the community and slowly leading to shifts in attitudes and behaviors. “It’s only together that the young generation can take better care – of each other and their environment,” Cavin Odera says. Making More Health’s collaborative and co-creative approach thus helps build trust and create synergies that radiate outwards.
Community activation is helping people to help themselves
An outstanding example of this is the Rusinga self-help group which consists of around 30 fisher families. Formed in the wake of the He4She and She4Him training sessions, this energetic and dedicated group of people aim to create sustainable change in their villages and lives. Participating in the mental health program made them aware that change is possible. It also encouraged them to begin advocating and acting for themselves. The group meets regularly and is focused on finding alternative sources of income to enhance their economic stability, including fishing, pig and poultry farming, boat building, and small business ventures.
They take part in all the training sessions which Making More Health offers on topics such as business and digital skills, health and hygiene, water conservation, and cultural awareness. By connecting, and implementing these solutions concurrently, the community will be able to change the trajectory of people’s lives in profound ways.
Health equity refers to the principle of ensuring that all individuals have the same opportunity to achieve optimal health outcomes. The concept goes beyond equal access to healthcare services by acknowledging that people have varying needs based on their unique economic, social and environmental circumstances. It recognizes that health disparities exist due to system-based and structural factors, e.g. poverty, unequal access to resources and opportunities and the impact of climate change and environmental degradation. It acknowledges that certain populations, such as racial and ethnic minorities, low-income individuals, and underserved communities, may face higher barriers that prevent them from attaining good health. These can include restricted access to quality healthcare, limited economic opportunities as well as inadequate education and health literacy. Health equity initiatives aim to address these systemic inequities by actively working to eliminate health disparities. This requires a multifaceted approach: Firstly, healthcare services need to be made accessible and affordable, particularly for underserved communities. Secondly, social factors which significantly influence health outcomes need to be addressed, e.g. poverty, education and employment. hirdly, biases within the healthcare system that contribute to health disparities need to be identified and adressed.Health equity is essential because it promotes social justice, upholds human rights, improves health outcomes, brings economic benefits, and enhances public health and well-being. So achieving health equity requires a collaborative and comprehensive effort of all the stakeholders involved so that every individual may have the opportunity to lead a healthy life, irrespective of their background or circumstances. |
Soap-making for health and economic autonomy
Several projects that WaWa and Making More Health co-created further illustrate how the issues of health, hygiene, and economic security are interconnected. One is a soap-making program which trains women and girls in how to manufacture much-needed cleaning agents for bathing, washing clothes and maintaining good personal hygiene. “This program has made soap readily available in the communities”, Cavin Odera confirms. This not only enables improved hygiene, which has an immediate impact on the women’s health. Soap-making also provides them with an independent, alternative source of income, thus decreasing their vulnerability to exploitative practices and damaging power dynamics, as well as dependency on the fishermen.
Building trust through practical support
Another income source for the women and girls living on Lake Victoria are self-made sanitary kits. The cotton pads and soap included in the kits are partly produced by WaWa, and the kits can be sold within the community. The impetus for this project also came directly from within the community. “We decided to do more life skills and reproductive health training for women and girls,” Cavin Odera explains. This led to WaWa establishing girls’ clubs where they educate young women about topics such as periods, sex, and pregnancies. During these sessions it became clear that menstrual hygiene was a larger issue. Making More Health offered its support in raising awareness and facilitating sanitary kit production. “Programs like this offer concrete support and build a lot of trust in the communities”, says global Making More Health leader of community work, Manuela Pastore.
Meeting communities at their point of need
That human health and economic stability are inextricably linked to animal health becomes clear by looking at a further program initiated in Rusinga. In conversation with the local fishing community, they repeatedly heard questions like: Why do we keep having epidemics that kill off our More Health’s Bag2TheFuture competition, where Boehringer Ingelheim employees worldwide are encouraged to contribute to different social entrepreneurial projects.
Tackling the fabric of society on the path to sustainable change
As increasing numbers of women and girls around Lake Victoria gain more economic autonomy, they become embodiments of a deeper change of the whole system they live in. But they are only one part of the equation. By taking a holistic approach which tackles the entire fabric of society, Making More Health and its partners are working on many fronts to address the entire ecosystem encompassing a range of complex and interlinked challenges. At the same time, they are listening carefully to underserved communities and collaborating with them, to empower themselves. Because a strong woman, supported by an empowered partner and family, is an important enabler for sustainable change in vulnerable communities.
“BEFORE I JOINED WAWA I WAS HAVING TROUBLE: YOU DON’T GET FISH FROM THE LAKE IF YOU DON’T FIND SOMEBODY TO HAVE SEX WITH. WAWA HELPED ME TAKE OUT A LOAN, SO NOW I HAVE MY OWN MONEY AND I AM FREE. I HAVE BECOME VICE-SECRETARY OF WAWA, AND WE DO THINGS TOGETHER AS A GROUP. IF I CAN CONTINUE WITH WAWA, I THINK MY LIFE WILL IMPROVE A LOT.”
Florence Kibaba (middle),former fishmonger and current vice-secretary of WaWa.
HOW DO WE DEFINE UNDERSERVED COMMUNITIES?
“People and animals who live in environments of inequality and face clearly demonstrated barriers to access healthcare.”
At Boehringer Ingelheim, a streamlined definition of who underserved communities are helps to better understand which barriers they face, their concrete needs and how our initiatives can deliver the most impactful and sustainable solutions.
According to our definition, underserved populations face barriers in the following key areas:
