Why Melinda Gates Sees Contraception as a Stepping Stone for Girls’ Dreams  

“All of these girls told me they want to be mothers—and they want to be good ones,” tweeted Melinda Gates on the heels of her visit to Adolescents 360 (A360)’s Smart Start, PSI’s flagship adolescent sexual and reproductive health and rights (ASRHR) program in Ethiopia. “They see family planning as a stepping stone to that and everything else they dream of.”  

The girls– like the tens of thousands who have engaged with Smart Start across Ethiopia, and the many others Gates met with during her recent trip have visions for their futures, and the tools today to make the decisions that will support them to achieve their life goals.  

But it wasn’t always that way. 

Photo Credit: Bill and Melinda Gates Foundation

In Ethiopia, girls face deep cultural pressures to start a family shortly after marriage. As a result, four in five girls will have their first baby by age 20, often before understanding the financial and health implications of having children too early, or in short succession 

Supporting Ethiopian girls to plan for the lives and families they want remains priority.   

That’s why in partnership with young designers, and alongside diverse experts including health system actors, the A360 Ethiopia team steps deep into the lives of girls and the health providers at the frontline to understand the diversity of their needsmotivations and constraintsand the holistic approach required to program in response. 

It’s a Smart Start for girls – and the health system that they rely on. 

Responding to Girls’ Holistic Needs  

Developed for Ethiopian young people, by Ethiopian young peopleSmart Start introduces contraceptive counseling through financial messaging designed to support rural Ethiopian girls aged 15-19 and their husbands to identify the resources they’ll need to achieve their life goals. Smart Start is integrated into Ethiopia’s Health Extension program and delivered through existing community structures, equipping health workers with the tools to respond to girls’ holistic needs 

The project is co-funded by the Bill and Melinda Gates Foundation (BMGF) and the Children’s Investment Fund Foundation, and was honored by the BMGF as a 2019 Goalkeepers’ Accelerator. 

Photo Credit: Bill and Melinda Gates Foundation

Lessons Learned 

Smart Start has catalyzed change, and fast – but it’s not without its hurdles. As A360’s latest technical publication, “Supporting Scalable, Youth-Powered Programming at the Community Level in Ethiopia: The Case of Smart Start,” documents: 

  • For A360,  youth-adult partnerships delivered (and continue to deliver) significant value – but challenges remain in what it takes to engage not only young leaders, but youth representative of the girls Smart Start serves. 
  • Following girls’ aspirations delivers an entry point to making contraception relevantBut as an implementing partner, PSI alone can only offer so much. Cross-sectoral partnerships allow for a more robust response, allowing diverse actors to bring their expertise to the table and collaborate so girls receive the higher-touch support they need – within and beyond their reproductive health. 
  • Married girls and their husbands told the A360 team that they desired a way to make joint decisions around their health and family. Still, A360 found that engaging husbands required a dose of both creativity and flexibility.
  • An eye toward sustainability is critical… from the get-go. A360 knew that responding to girls was essential – but initially failed to consider the motivations and real-life constraints of the health actors who would deliver Smart Start. Addressing their needs would have pre-empted subsequent adaptations to ensure sustainability.  

Where We’re Going, Next 

Starting in early 2020, PSI will integrate Smart Start within the public health system through RISE, a $7.5 million investment from the Children’s Investment Fund Foundation. The investment will scale Smart Start to reach up to 500,000 new contraceptive users by 2024, supporting Ethiopia in reaching its FP2020 goals and the SDGs. 

Through Smart Start, PSI has made inroads in what it takes to motivate girls to voluntarily take up contraception. And through RISE, PSI commits to continuing A360’s learning journey by exploring how to support girls to choose to stay on a method, for as long as works best for them.  


It’s simple: access to contraception is not just about protecting girls from an unintended pregnancy today— as Gates noted, it’s about supporting girls to achieve their life dreams, now and into the future.