Student Spotlight on a Discovery Experience with the Armenian Ministry of Health
DGSOM students in the Global Health Equity Pathway are focusing on global health equity during the inaugural Discovery experience as part of DGSOM’s HEALS curriculum. Two-thirds of the seventeen students in the Global Health Equity Pathway work on projects abroad. Our students are engaging in a variety of research, public health, and advocacy projects, which will result in a range of outputs including investigative manuscripts, think pieces, and other outputs that have been shaped by their partner sites. We intend for these collaborations with partners around the world to have positive impacts that extend beyond this year.
GHP connected with Shivani Dayal, MS3, to reflect on her experience in Armenia as part of the global health Discovery Experience!
What drew you to the Global Health Equity Pathway as your focus for the Discovery Experience?
Shivani: I chose UCLA for medical school because of the DGSOM Global Health Program! I’ve been passionate about global health for a long time, largely due to my personal experiences witnessing global health disparities in India every year when I visited my dad’s family, so after graduating from college I got my MPH in Global Health to gain more tangible skillsets in the field. The GHP at DGSOM stood out to me because the Discovery curriculum would allow me to spend several months in country, and a big part of doing global health as ethically as possible (in my perspective) is trying to be on the ground so that you can understand a community as much as possible. The Global Health Equity Pathway allows me to do that within long-standing existing relationships.
What got you excited about working in Armenia?
Shivani: For my Discovery Experience, I was open to any location, but I really wanted a project that was about public health “practice” as opposed to pure research — I wanted to do something related to implementation science. I’m also really interested in health system strengthening and health governance. When I heard Dr. Shekherdimian talk about his work with the Armenian Ministry of Health, it immediately caught my attention and he and I started brainstorming ideas of how my skillsets could contribute to their primary care strengthening work. Armenia is at a crossroads right now in terms of rebuilding their healthcare system and so the chance to contribute to a system that would have national impact was incredibly compelling.
On a personal level, I was also drawn to this work because I could tell I would receive great mentorship from both my in-country mentor, Dr. Libaridian, and my UCLA mentor Dr. Shekherdimian — and in global health especially, good mentorship makes all the difference.
Could you provide your “elevator pitch” on your Discovery Year project?
Shivani: Armenia, an upper-middle income country of 2.9 million, has struggled to transform the underfunded, inefficient, Soviet-era model of care into a functional, responsive system. Weak primary care significantly hinders the healthcare system where (uncontrolled) non-communicable diseases cause 93% of mortality. The Armenian Ministry of Health and key stakeholders recently designed a primary care pilot program to trial different reform strategies related to universal health coverage, focusing on diabetes (DM) and hypertension (HTN). Pilot interventions include providing pathways for screening/diagnosis, provider education on disease management, free HTN/DM medications and lab testing, and new financial incentives for providers. However, for data from the pilot to eventually help inform the national scale-up of primary care reform strategies, there needs to be a robust monitoring and evaluation (M&E) system. My role as the M&E Specialist has been to develop the M&E framework, logic model, and log frame; select and develop key indicators; build program data dashboards and data collection tools; develop focus group guides; and analyze qualitative data and electronic medical record (EMR) data to assess baseline primary care. So basically, my job is to figure out how we are going to know if this program is working and if not, why?
How does this project fit with the partners’ goals and needs? Are there any next steps in place after you transition away from the project and into residency?
Shivani: The Armenian government aims to establish universal health coverage by 2027 and has already taken steps to invest in strengthening primary care. This project was completely driven by the partners — I arrived in Armenia last year to lay the foundation for the project with no agenda except to learn about the ongoing primary care reform work and see how my skillsets might fit in, and after many conversations it became clear that having me be the M&E Specialist would help the program the most. I’m very glad I can support an existing program because, even with that, myself and my mentors still have had to continuously advocate for the importance of the program to be pushed forward. If we’re able to show that it’s cost-effective for the government to provide HTN/DM medications for free and that health outcomes improve with better disease management training, then these interventions will inform the scaling of national primary care and impact the whole country.
In terms of sustainability, I always try to think about that from the beginning, so I’ve already written user manuals/guides that include step-by-step instructions on how to use and update the data dashboards I’ve built, for example. This way any future student, intern, or employee who is tasked with doing the routine M&E will know exactly what to do. In terms of my involvement, I will have six weeks of research time in Fall 2024, which I will use to continue my work depending on where the project is at that point in time, and I would love to stay involved during residency. There’s also the chance that future DGSOM students may want to continue some my work for their Discovery Year, which would provide great continuity!
What are you most proud of? What has been your biggest challenge?
Shivani: I’ll start with the challenge — the biggest challenge has been around data access and data generation. In Armenia, there is not a culture of collecting data to make policy changes or make evidence-based decisions due to the historically ingrained Soviet system of top-down orders from the government. This means it takes a lot of work to explain to different stakeholders why we need certain data for M&E. In general, when you want to evaluate the effectiveness of a program like this, you want to gather pre- and post-program data, but baseline data is very limited (and sometimes nonexistent) and it has taken a lot of effort to get access. The electronic medical record system has just started to be utilized in clinics, so it’s hard to pull data and requires cross-checking paper charts, which is a lot of additional work. I’m optimistic though data in Armenia will be a lot more readily available for research and improvement purposes in the future.
Despite these challenges, I am most proud of how much we’ve been able to do so far and making a contribution towards shifting mindsets to be more data-oriented. For example, ArMed (the national Armenian EMR company) is studying one of my M&E dashboards to consider integrating components into the national EMR!
What would you say is the most important thing you learned from this experience?
Shivani: Nothing operates on your timeline! Everything takes longer than you think, even things that seem quite basic. I’ve also learned a lot about the nuanced relationships between governments and non-governmental organizations and how issues of ownership and stakeholder engagement are so essential to program success.
I think the theme of my experience is summarized by the word “pivot” — I keep telling people that I feel like a mouse running in a maze and every time I think I have a straight shot forward, a new wall suddenly emerges in front of me that forces me to pivot in a different direction. But the important thing is not to stop and lose momentum, and to keep pivoting and problem solving. It’s an important skill to develop.
Thank you for sharing about your Discovery Experience, Shivani!
Photo caption: Shivani (middle), a co-investigator, and their mentor Dr. Libaridian.