Smart Start is an innovative ASRH approach, designed under the initial A360 investment, which uses financial counseling as a hook to elicit discussions with married adolescent girls and their husbands around delaying and spacing births. Smart Start is implemented within existing public health structures, primarily at the health post level, leveraging the critical presence and engagement of Health Extension Workers (HEWs) in the community. Mobilization of married adolescent girls for services is conducted both through the HEW as well as other existing community-level structures (such as the Women’s Development Army (WDA), a volunteer community-level cadre which supports mobilization and health promotion activities).

Either through a home visit or at the health post, HEWs then provide counseling using the Smart Start counseling tool. This counseling session can be provided either individually to a married adolescent girl or to a married adolescent girl and her husband together as a couple. This counseling tool uses compelling visuals and analogies to support girls and couples to envision their goals for the future and understand how delaying and spacing births is relevant for the future health and prosperity of their family. After conveying this messaging, girls are provided with contraceptive counseling and service provision should they choose to take up a method.  Girls can choose to take home a goal setting card that they have filled out during their session, to use as a prompt for discussion with their partners or other influencers regarding their goals and contraceptive use.

Family Circle is an adaptation of Smart Start, designed for the unique needs and experiences of married adolescent girls in pastoralist regions in Ethiopia. Family Circle helps couples and key community influencers, including Traditional Birth Attendants (TBAs), to see the health benefits of contraception. Unlike Smart Start, the entry point for Family Circle, as explained in the Family Circle discussion aide (available in English / Somali or Afari / Amharic), is maternal-related health complications from multiple pregnancies. Family Circle is crucial in linking married adolescent girls to service delivery points, supporting them to learn about contraceptive methods they can use to delay and space pregnancies and pursue their goals and aspirations. 

Smart Pathways is an adaptation to Smart Start which creates demand for ANC and promotes self-efficacy among pregnant adolescent girls and young women (AGYW) and AGYW at risk of pregnancy, driving higher care seeking behaviors. Smart Pathways: 

• Frames ANC as an investment in future wellbeing
• Provides clarity for AGYW about what happens at ANC
• Gives AGYW tools to discuss the importance of ANC with their husbands
• Builds self-efficacy by helping AGYW map out the concrete steps – emphasizing ANC attendance and nutrition – they can take to care for themselves during preconception and pregnancy
• Introduces PPFP early in pregnancy leveraging the core Smart Start messaging

Smart Pathways is implemented using the Smart Pathways counseling guide – meant to be a continuation of Smart Start counseling particularly for AGYW who choose not to take up a method. For pregnant AGYW, they are also able to utilize a Smart ANC guide throughout the course of service delivery during pregnancy. 

Through an additional investment from the Bill and Melinda Gates Foundation (BMGF), PSI Ethiopia is currently expanding the work of Smart Pathways to be a cohesive brand that can support demand and service delivery across the RMNCH continuum of care. 

Smart Steps is an adaptation of Smart Start designed to support married adolescent girls ages 15-19 to identify and act on their goals. Through Smart Steps, girls are supported to join Step-Up Associations, designed in the model of Village Savings and Loan Associations (VSLAs) to learn basic business management skills, save money, and access low-interest loans to launch or grow their businesses.

Smart Steps supports married adolescent girls across the span of 9 months to plan for and pursue their economic and life goals.

• Smart Steps begins with two in depth goal setting sessions, first with a girl and her husband and then a girl individually.
• Girls who are interested to participate are then gathered together into Step Up Associations where participants save weekly.
• After 5 weeks of saving participants can take low interest loans from their own savings pools.
• At weekly meetings, girls receive interactive, low literacy education sessions on key skills required for success in business, such as: negotiation, skills identification, profit / loss calculations, and more.
• After 20 weeks, associations are eligible for a matching grant that matches the groups’ total savings at 150% and increases the pool available for loans.
• In addition, specific outreach is done with husbands to secure their support for the program and educate them on the importance of women’s economic activity.

RISE is being implemented by the MOH, with PSI/E providing important technical assistance to institutionalize Smart Start into the government’s successful Health Extension Program (HEP) and scale to 11,000 kebeles across the major agrarian regions in Ethiopia. 

This process of institutionalization and government-led scale has required PSI to transition from direct implementation role to a TA provider to the government. The TA that is provided by PSI to scale through the MOH cuts across all WHO health system building blocks with the aim of sustainably strengthening the health system to provide adolescent-responsive demand creation and service delivery beyond the life of the RISE investment. 

To implement RISE TA, PSI Ethiopia deployed personnel to support national-level activities. These staff are based at PSI’s Ethiopia’s headquarters in Addis Ababa, as well as at the headquarters of the six RHBs (in Southwest Ethiopia’s People’s Region (SSNPR), Oromia, Amhara, Sidama, Afar, and Somali) where RISE is currently being implemented.

Personnel at the RHB level provide support to the RHBs, the administrative zone level, woreda health offices, PHCUs, and HPs. The RHBs are staffed with five technical officers. Personnel based outside of Addis Ababa also provide supervision and technical support to their peers who are based at the regional level.

Further detail on the specific activities and desired outcomes from this TA approach are found in RISE’s TA framework.