Adaptive Implementation, From the Desk of an A360’er

By Metsehate Ayenekulu, Adolescents 360 Ethiopia Program Director, PSI/Ethiopia

As Ethiopia’s program director for Adolescents 360 (A360), I tell you firsthand: utilizing tools to structure how a project transitions from design to implementation is fundamental for success.

In public health—and beyond—optimizing programs requires that we maintain the quality and efficacy of our operations as we take projects to scale. To meet these goals, I’ve found tremendous value in an adaptive implementation approach to guide me, and my team, as we enter A360’s optimization phase.


A360 Ethiopia is a trailblazer driving adolescent and youth sexual and reproductive health (AYSRH) for married girls across our nation’s rural regions. In Ethiopia, the demand for sustainable AYSRH efforts is high: across A360 Ethiopia’s focal areas, 581 thousand married 15-19-year-old girls do not want to get pregnant—yet, at the start of our efforts, 228 thousand girls did not have access to modern contraception.

With young people at the helm of our work, we, together, developed Smart Start, a program that initiates contraceptive counseling through financial planning. Through our program, girls, alongside their husbands, can map out the cost of a baby in culturally relevant terms (like, a bag of grains) to explore how spacing out child birth can help couples plan for the lives they want to live. It’s a process that is achieving rapid results: since our August 2017 pilot, approximately one in two girls who interact with Smart Start adopts a contraceptive method.

In the two years since our project launch, and a mere ten months since our pilot kickoff, our team is prepped to enter the project’s adaptive implementation process. This optimization stage is another chapter in a project rooted in transition; the design of our intervention is near finished, but the magic behind the evolution of our work continues.


A360’s adaptive implementation approach has influenced how we, across A360’s three intervention countries, pursue readiness for scale. We want an intervention that is sustainable, sensitive to changing contexts, and capable of adapting in response. Our adaptive implementation approach allows us to re-assess the types of data, and the diversity of team members we’ll need to engage as we get deeper into A360’s final phase.

These steps—which I outline below—are ones that all projects can replicate as they too navigate the journey to scale.

“Adaptive implementation is yet another milestone under A360’s wing. I welcome this ­­­­­next stage, armed with a tool to structure how I embrace the forks in our road to success.”— Metsehate Ayenekulu, Adolescents 360 Ethiopia Program Director

  • Start by identifying the support your project will require. Setting team roles and responsibilities provides a clear way to identify who can best support evidence-based decisions. For us, we reorganized our team into two: a learning group and an operations cohort, and instituted weekly team meetings to streamline knowledge sharing between our staff. This guarantees that we’re all on the same page as we work toward optimization, together.
  • Narrow your “learning field” by establishing measurements for high vs. low-performing sites. We consider the conversion rate of how many girls adopt a contraceptive method, and the percentage in unmet need satisfied. Our learning team uses this data to explore what elements leads us to higher adoption rates in some locations over others. That’s been critical insight for us as we build out, weekly, across news sites.
  • Plan and collect your information early, and often. Outline the data and information you need. From there, map out how often you’ll collect it, where the information will be gathered from, who will lead the process and who will use it for decision making. Think through what tools will assist you to collect, analyze and use the information. What do you have on hand—and what will you need?
  • Use the data to identify issue areas you want to address, and then prioritize how you plan to respond. These can be either positive successes or challenges. As a team and, as applicable, alongside project partners, brainstorm adaptations to respond to these identified issues. Your responses should follow agreed upon criteria, such as cost or alignment with what your target populations say they need.
  • Apply your adaptations, measure your success, capture your learnings: Setting Key Performance Indicators has given us consistent messaging for how we define success across the process and outcome levels. Create a record of the adaptations you’re making and the impact it’s having. This will be prime material to reference again and again as you not only continue optimizing your solution, but as also as you share your findings for others to learn from.

A360 Ethiopia’s efforts have been ripe with accomplishments, but it’s not been without change and, at times, challenge. Adaptive implementation is yet another milestone under A360’s wing. I welcome this ­­­­­next stage, armed with a tool to structure how I approach—how I embrace the forks in our road to success.

Adolescents 360 (A360) is a four-and-a-half year initiative co-funded by the Bill & Melinda Gates Foundation and the Children’s Investment Fund Foundation (CIFF). The project is led by Population Services International (PSI) together with, University of California at Berkeley Center on the Developing Adolescent, the Society for Family Health Nigeria, and Triggerise. The project is being delivered in Ethiopia, Nigeria and Tanzania, in partnership with local governments, local organizations, and local technology and marketing firms. In Tanzania, A360 is building on an investment and talent from philanthropist and design thinker Pam Scott.