Get Smart: Learning and partnership with Ethiopia’s Health Extension Programme to re-envision contraceptive service delivery to young couples

Abstract

Background: Adolescents 360 (A360) implements the Smart Start (SS) programme through Ethiopia’s Health Extension Programme (HEP). SS is premised on financial planning as an entry point to discuss family planning (FP) with newly married couples and central to its delivery are the health extension workers (HEW). This article evaluates the A360 experience and learning from the process evaluation implemented by Itad to understand contextual barriers and enablers from the perspective of the HEW. Methods: A purposive sampling strategy was employed whereby 27 key stakeholders were identified from Oromia, Addis Ababa and Amhara, based on exposure to the SS programme. Findings from the action research were shared with A360 through a one day sounding workshop. Results: Findings revealed that many local government and communal respondents do not view adolescent pregnancy as a problem, unless out of wedlock, and adolescent pregnancy is closely linked to early marriage. As a result, some providers, including HEWs, acknowledged that married adolescent girls were previously ‘neglected’ by them, while husbands indicated that they had not previously been included in FP counselling. Findings also revealed some challenges with SS implementation as HEWs were ‘deprioritizing’ the intervention and many HEWs had been in situ for several years and were overworked and frustrated. Against this backdrop, A360 was viewed as adding to the HEW workload. While the programme design was focused on adolescent users, there was increasing recognition that HEWs also needed to be at the centre of solution design. Conclusions: Despite challenges associated with the HEP, Ethiopia FP2020 plans to support the ‘next generation’ of HEWs, including a focus on adolescents and youth. To gain deeper insight and put the HEW at the centre of design, A360 will continue to work with the process evaluation to understand contextual barriers and enablers from the perspective of the HEW.

Policies for expanding family planning coverage: lessons from five successful countries

“…Ethiopia’s commitment to FP2020 and FP2030 initiatives, among other priorities, prioritized adolescents, regardless of marital status, introducing school-based family planning programs and a new cadre of health extension workers trained to serve youth ( 169 , 170 ). The outcomes encompassed the Adolescent and Youth Health Strategy (2016–2020), enhancing adolescent information access and education while elevating the quality of youth-friendly health services ( 171 ), Actions for Acceleration (2018–2019) further aimed at curbing adolescent pregnancy, enhancing family planning among youth, with a particular focus on long-acting methods ( 172 ), and the A360 program focused on contraception among girls and young married couples ( 169 , 173 ). Through a transdisciplinary approach, A360 merges public health, human-centered design, adolescent developmental science, socio-cultural anthropology, youth engagement, and social marketing, employing these diverse lenses to yield country-specific adolescent and youth sexual and reproductive health solutions ( 169 , 174 ).…”

“…The outcomes encompassed the Adolescent and Youth Health Strategy (2016–2020), enhancing adolescent information access and education while elevating the quality of youth-friendly health services ( 171 ), Actions for Acceleration (2018–2019) further aimed at curbing adolescent pregnancy, enhancing family planning among youth, with a particular focus on long-acting methods ( 172 ), and the A360 program focused on contraception among girls and young married couples ( 169 , 173 ). Through a transdisciplinary approach, A360 merges public health, human-centered design, adolescent developmental science, socio-cultural anthropology, youth engagement, and social marketing, employing these diverse lenses to yield country-specific adolescent and youth sexual and reproductive health solutions ( 169 , 174 ). In 2021, Ethiopia’s FP2030 commitment centers on augmenting family planning financing, securing contraceptive commodities, and bolstering adolescent access while ensuring quality information and service availability.…”

“…Enduring barriers include an unsupportive environment, negative attitudes of providers toward unmarried youth, supply constraints, poor implementation, inadequate multisectoral engagement, lack of parental and social support, gender inequality, and adolescents’ incomplete awareness and attitudes about sexual and reproductive health ( 136 , 177 ). Additionally, within the HEP, the intersection of family planning and adolescents is maternal and child health, only when a married adolescent becomes pregnant ( 169 ).…”

Unmet need for family planning among rural married women in Ethiopia: What is the role of the health extension program in reducing unmet need?

“…One study conducted elsewhere in Ethiopia showed that level IV HEWs have better knowledge and skill in performing long acting FP methods than level III HEWs, which allows the level IV HEWs to make available more options of FP methods for their clients [ 29 ]. Thus, strengthening the capacity of HEWs by upgrading their qualifications has the potential for creating favorable ground for married women to get more options of FP methods [ 30 ], to decrease unmet need, and to increase FP use.…”

Unmet need for contraception among married adolescent girls and young women in Haramaya Health and demographic surveillance system, Eastern Ethiopia

“…Currently, Ethiopia is committed to increasing contraceptive use among 1 million adolescents and youth by 2025 through the smart start program. The program uses financial planning as an entry point to engage young married couples in planning their futures and achieving financial stability, positioning contraception as a tool to help them achieve their self-defined goals ( 13 ).…”