A Smart Start for Ethiopia’s Health System

In Ethiopia rural primary care runs through the country’s Health Extension Program (HEP).

But with an overstretched HEP and overworked Health Extension Workers (HEWs), the country’s health system faces a challenge: effectively and affordably delivering reproductive care to the two in five girls aged 15-19 who want, but don’t have access to modern contraception.

Smart Start supports the HEP’s efforts to “catch-up” by serving all married girls and their partners in some of Ethiopia’s hardest to reach communities. By working in partnership with HEWs and by engaging community leaders, Smart Start delivers a solution to close a pervading unmet need, while leaving behind a health system capable of continuing coverage.

Through participatory action research and literature review, A360’s evaluation partner Itad identified the facilitators and challenges that HEWs faced when using Smart Start.

We knew Smart Start was sparking a catalytic effect for the HEWs using it to engage young married couples. But through Itad’s independent evaluation, we found gaps in where we were, and where we weren’t equipping HEWs to effectively navigate a complex portfolio of services.

We responded by adapting the program.

We shortened the couples counseling curriculum to lessen the time burden on HEWs and we shifted from a house-to-house model to reach and mobilize young couples to, instead, a system that shares demand generation efforts with existing community structures, including the Women’s Development Army.

We outline here the topline findings from Itad’s evaluation of Smart Start.


What we’re doing

A360’s Smart Start introduces targeted financial messaging designed to help adolescent rural couples plan for the families, and lives, they want. By outlining what it takes to raise a child in contextually relevant terms (i.e. a sack of grains), Smart Start galvanizes young couples to understand the health and economic benefits of pregnancy spacing. Smart Start builds on the national dialogue of progressing beyond development needs. It’s a lens that girls and their communities not only understand, but embrace.

How we’re doing it

Smart Start works with community networks, including the Women’s Development Army and men’s agricultural groups, to identify girls at key moments—engagement, marriage, pregnancy and her first child. HEWs then proactively facilitate discussions with girls and their husbands about the resources they need to achieve their goals.



Landscape analysis

Ethiopia’s FP2020 pledge commits to supporting HEWs deliver services, while expanding LARC access for all women, including girls. But while motivation among HEWs remains high (they cite improving maternal and child health as a key driver), one common theme threads among those at the frontline: they are overworked and overextended.

HEWs’ workload, by season

For HEWs, busy season falls during dry season in which they conduct household outreach. Rainy season corresponds with short-term contraceptive discontinuation (feeding the MOH’s priority to build capacity for LARC distribution). Wedding season presents a complex mix: on the one hand, it’s a key period for HEWs to promote contraception On the other hand, the cultural norm for girls to secure their marriage by proving their fertility makes traditional reproductive health messaging—namely, planning families to finish school— ineffective.


What we’re doing

Smart Start gives HEWs targeted, evidence-based messaging that speaks directly to where girls and their partners are cognitively, emotionally and socially. HEWs state that the manual is “attractive” and “engaging” – and gives them a framework to guide young couples in identifying the resources they need to pursue their life dreams.

What we’re recording

Smart Start makes contraception relevant to their lives, today. And it works. Since January 2018, A360 Ethiopia has served 7,230+ girls with a contraceptive method (Figure 1). One in two girls who interacts with Smart Start takes up contraception. 24 percent of adopters choose a long-acting method (LARC)—a number that remains higher than Ethiopia’s national 18 percent average of LARC uptake among the same age group.

How the HEP is responding

Providers report that Smart Start helps health posts function better by forging links to health seeking behaviors within communities. High performance HEWs say that they turn to Smart Start to help meet girls’ growing demand for family planning. Still, they say, the manual doesn’t have all the answers to girls’ questions and takes at least an hour to run through. “A short hand of the manual would be important,” a HEW said in the report.

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Itad outlines the areas Smart Start will need to address as it adapts Smart Start for long-term sustainability.

  • How can we optimize Smart Start around HEWs’ seasonal variations to make it easier, and faster, for HEWs to deliver the counseling?
  • Should Smart Start broaden its focus from recently married adolescents to those who have been married for some time and may already have a child/children
  • Should Smart Start address unmarried adolescents?
  • HEWs are motivated by improving maternal and child health. Will that motivator remain even in the absence of an unintended pregnancy?
  • How can Smart Start engage men—both in mobilization and in family planning through financial planning?
  • What motivates mothers to bring their daughters to counseling before marriage?
  • What is the cost benefit of Smart Start to the MOH and communities?

These questions served our North Star as we, alongside IDEO.org, launched a design sprint in August 2018 to inject a new end-user at the end of the HCD process: the HEW. The resulting prototype will deliver HEWs with a shorter discussion aid that reaches newly married girls. As we drive toward scale, our focus centers on ensuring Smart Start’s sustainability as a solution that speaks not only to the girls we serve, but to the health system that will ultimately own Smart Start’s way forward.

HEWs practicing the shorter discussion aid, a prototype developed following IDEO.org and A360’s Aug. 2018 design sprint.
HEWs practicing the shorter discussion aid, a prototype developed following IDEO.org and A360’s Aug. 2018 design sprint.