The main objective of this component is to increase the capacity of the GOAM to establish an Overarching Quality Management system including a system of sustainable Quality Improvement (QI) processes in targeted health areas.
Quality Management System Strengthening
HS-STAR builds on the accomplishments and lessons learned from USAID’s Primary Health Care Reform (PHCR), NOVA 2, and NOVA projects and aims to enhance the achievements of these projects, namely improve the overall regulatory environment for service delivery by emphasizing the establishment of a culture of data-driven decision making, supportive supervision, participatory management, and enhancing bottom-up initiatives.
Quality Assurance (QA) mechanisms have remained contentious in Armenia and these systems have not been significantly improved or refined in recent years.
HS-STAR NCD Advisor Karine Abelyan (in the left) and MCH/RH Advisor Gohar Panajyan (in the right) during a conference
Despite the introduction of the National Quality in Health care Concept by MOH, presently the government‘s and Marz health authorities’ interest and commitment to taking ownership of a new QA intervention are not always clear. The functional “responsibility centers” (Quality Improvement Boards) established with PHCR Project support at all three levels (facility, regional and national) require further strengthening of their stewardship role to assure sustainability of PHCR-introduced QA regulatory mechanisms and tools.
HS-STAR continues to conduct policy dialogue with the MOH and other relevant stakeholders to come to agreement on QA approaches that define clear institutional roles and relationships and separation of functions to improve transparency and governance. HS-STAR provides technical assistance to help further develop QA strategies and plans, and builds capacity of the organizations involved to fulfill their agreed upon functions.
Provider Performance Improvements
The core-underlying issue of quality systems in post-Soviet countries is rigid Clinical Practice Guidelines (CPGs) that are not anchored in Evidence Based Medicine (EBM) or best practices, and are applied in a punitive fashion. Facility-level QI techniques alone cannot improve the content of clinical practice – better process on top of bad practice does not improve quality. HS-STAR will ensure that roles and relationships for CPG/job aid development and implementation are clear, and will support the process to ensure that a CPG, job aid, clinical protocol, or WHO standard is approved for implementation before undertaking reinvigorated facility-level QI activities. In addition, HS-STAR provides access to international literature, train counterparts to analyze relevant literature, and ensure that all training modules provide the rationale for clinical practice changes to avoid reversion to established practices after training.
QI Team advisors Murad Kirakosyan (in the front), Karine Gabrielyan (in the front) and Gohar Panajyan (standing, top right) at an orientation course on Preconception Care
For priority MCH/RH/NCD programs selected, HS-STAR will empower counterpart organizations to ensure that CPGs/job aids including quality/performance indicators are approved by all stakeholders, develop and implement targeted CME packages on priority health topics, support implementation of the facility-level QI process and ensure sustainability options for programmatic interventions. The facility-level QI process will include identifying specific problems to be solved, implementing operational solutions to problems, establishing supportive supervision mechanisms, monitoring indicators, and ensuring feedback loops to marz and national health authorities for policy dialogue, CPG/job aid development, and health information system (HIS) improvement.
Establish Mechanisms to Monitor Provider Performance against Selected Indicators
QI Team advisors Karine Abelyan (in the right) and Gohar Panajyan (2nd from the right) presenting the results of USAID’s Maternal/Newborn/Non-Communicable diseases assessment
HS-STAR works with the newly established QM division at MOH, SHA, national and marz-level Quality Improvement Boards to establish system-level mechanisms to monitor provider performance against selected indicators and to build their capacity in analysis and use of information to monitor health care quality and health system performance. This activity will largely be accomplished by implementing the planned pay-for-performance mechanism, which rewards PHC providers for improvements against selected indicators collected through the MIDAS 3 system. The indicators will focus on health priorities including MCH/RH/FP/NCD creating incentives for PHC providers to improve these services.
Emergency Care
Working closely with national training institutes, HS-STAR addresses emergency care Continuous medical Education (CME) for both ambulance staff and first contact providers, including PHC professionals. As part of the process to develop the CME program for emergency care, HS-STAR supports the MOH to develop and/or update clinical guidelines and practice standards for emergency care and ambulance services. Commodities and rehabilitation support could be used to provide basic medical equipment for emergency rooms and/or standard equipment for ambulances. This support will be conditional on GOAM/MOH achieving agreed-upon reform milestones and preconditions. As with commodities to support to PHC facilities described above, HS-STAR will train providers on proper handling, storage, use, and disposal of medical waste associated with commodities procured to support emergency care services. 
