Piloting Health System Integration in Northern Ethiopia

By: Bryan Molk, AYSRH Regional Peace Corps Volunteer, PSI/Ethiopia 

In Northern Ethiopia’s Tigray region, government health professionals have increasingly incorporated Smart Start into their outreach – using the financial planning module to meet the reproductive health needs of last-mile married girls aged 15-19 too often left behind in the district’s over-crowded health system.   

In Ethiopia, Adolescents 360’s (A360) Smart Start program responds to young couple’s expressed concern about uncertain futures amidst a shifting economic landscape and resulting desire for a better quality life for themselves, their families and their futures. Blending adolescent developmental science with social marketing, cultural anthropology, adolescent and youth sexual and reproductive health (AYSRH) and Human-Centered Design—all driven by the insights and leadership from young people themselves—Smart Start delivers girls and their partners a pathway to identify how they can achieve financial stability and their self-expressed dreams for a brighter future.

Smart Start’s empathetic and pragmatic approach equips community-based health extension workers (HEWs) and their local government health offices to reach young couples with a message that they, and their communities, not only understand but embrace. 

That’s evidenced best by a Tigray outpost chosen by the region’s health office as a pilot site for Smart Start’s integration.  

Smart Integration

Like all districts, Tigray had a family planning (FP) plan in place prior to Smart Start – but as a local FP focal person noted, the plan was “just numbers [for how many girls the health office wanted to reach]” with often no measures in place for how to meaningfully engage and serve the target population.

Smart Start delivers an overstretched system the tools and thereby capacity to respond to gaps in the area’s AYSRH services. Through Smart Start, Tigray’s local community groups like the Women’s Development Network (WDA) recruit girls; HEWs lead the counseling; and the health office collects the data on the girls who engage with and voluntarily uptake a contraceptive method.   

“HEWs in other kebeles are advocating for Smart Start to other HEWS in different kebeles, so other HEWs are excited to take the Smart Start training in the future.” – Family Planning focal person

The intervention is catalyzing health system capacity to reach girls with timely services. It’s also sparking regions’ ability to steward more evidence-based FP programming.

Here’s a breakdown of how it works:

Step 1: WDAs support the government health office to identify the number of married girls aged 15-19 in their community, which allows the Smart Start focal person to develop a clear, effective and realistic Smart Start strategic plan for implementation.  

Step 2: WDAs recruit married girls aged 15-19 in their villages and introduce them to Smart Start, providing referrals to HEWs at girls’ local health post.  

Step 3: The health office’s family planning focal person distributes Smart Start session tracker forms to the HEWs working at the health post.  

Step 4: The HEWs fill out a form after each individual counseling session.   

Step 5: The focal person travels back to the health post every week to collect the forms, which they will use to report back to the health office head on how many girls are taking up a contraception method.   

Step 6: The health office’s focal person uses the information from the WDA-led community assessment to determine the girls who have and haven’t been reached with Smart Start. That raises the question: did WDAs effectively identify and recruit the married girls in their community, and are WDAs seeing short-term behavioral changes in girls’ everyday lives?  

Step 7: Using the data, the local health office elevates results to the Tigray regional health bureau to demonstrate how Smart Start drives impact quickly and cost-effectively, reinforcing why the intervention should remain a cornerstone for Ethiopia’s family planning strategy.  

Three Months In

It’s been three months since the Tigray health system has taken the wheel in applying Smart Start into how HEWs and the WDA reach, inspire and serve the community’s young couples. There’s a committed spirit among all involved backed by a formula in favor of accountability: HEWs, WDAs, and the family planning focal person are ensuring transparency at all levels of program operations by allowing the knowledge of community-based WDAs to influence strategic plans and target goals for the government health office’s plan for long-term Smart Start implementation.  

“The best part about Smart Start was that it helped me initiate a conversation with my husband.” – Smart Start Participant

“We will see the results (from Smart Start) in the next generation of healthier children” -WDA

From Micro to Macro

So, how might this community’s success and experience with independently integrating Smart Start into their local government’s family planning strategy influence our Ethiopia-wide scale up process? Not sure yet, but one thing is for sure: A360 will use this community’s experience as a standard for how other government health offices can find independent and sustainable success with Smart Start.