Time for action: key considerations for implementing social accountability in the education of health professionals

Within health professional education around the world, there exists a growing awareness of the professional duty to be socially responsible, being attentive to the needs of all members of communities, regions, and nations, especially those who disproportionately suffer from the adverse influence of social determinants. However, much work still remains to progress beyond such good intentions. Moving from contemplation to action means embracing social accountability as a key guiding principle for change. Social accountability means that health institutions attend to improving the performance of individual practitioners and health systems by directing educational and practice interventions to promote the health of all the public and assessing the systemic effects of these interventions. In this Reflection, the authors (1) review the reasons why health professional schools and their governing bodies should codify, in both curricular and accreditation standards, norms of excellence in social accountability, (2) present four considerations crucial to successfully implementing this codification, and (3) discuss the challenges such changes might entail. The authors conclude by noting that in adopting socially accountable criteria, schools will need to expand their philosophical scope to recognize social accountability as a vitally important part of their institutional professional identity.

Coordinating medical education and health care systems: the power of the social accountability approach

CONTEXT

As the purpose of medical education is to produce graduates able to most effectively address people's health concerns, there is general agreement that coordination with the health care system is essential. For too long, coordination has been dealt with in a subjective manner with only few landmarks to ensure objective and measurable achievements. Over the last 30 years, since the Edinburgh Declaration on medical education, progress has been made, namely with the concept of social accountability.

METHODS

The social accountability approach provides a way to plan, deliver and assess medical education with the explicit aim to contribute to effective, equitable and sustainable health system development. It is based on a system-wide scope exploring issues from identification of people's and society's health needs to verification of the effects of medical education in meeting those needs. A wide international consultation among medical education leaders led to the adoption of the Global Consensus on Social Accountability of Medical Schools.

EXPERIENCES

Benchmarks of social accountability are in the process of being conceived and tested, enabling medical schools to steer medical education in a more purposeful way in relation to determinants of health. A sample of schools using the social accountability approach claims to have had a positive influence on health care system performance and people's health status.

CONCLUSION

Improved coordination of medical education and other key stakeholders in the health system is an important challenge for medical schools as well as for countries confronted with an urgent need for optimal use of their health workforce. There is growing interest worldwide in defining policies and strategies and supporting experiences in this regard.

Producing a socially accountable medical school: AMEE Guide No. 109

Health systems worldwide are confronted with challenges due to increased demand from their citizens, an aging population, a variety of health risks and limited resources. Key health stakeholders, including academic institutions and medical schools, are urged to develop a common vision for a more efficient and equitable health sector. It is in this environment that Boelen and Heck defined the concept of the "Social Accountability of Medical Schools" - a concept that encourages schools to produce not just highly competent professionals, but professionals who are equipped to respond to the changing challenges of healthcare through re-orientation of their education, research and service commitments, and be capable of demonstrating a positive effect upon the communities they serve. Social Accountability calls on the academic institution to demonstrate an impact on the communities served and thus make a contribution for a just and efficient health service, through mutually beneficial partnerships with other healthcare stakeholders. The purpose of this Guide is to explore the concept of Social Accountability, to explain it in more detail through examples and to identify ways to overcome obstacles to its development. Although in the Guide reference is frequently made to medical schools, the concept is equally applicable to all forms of education allied to healthcare.

Is our medical school socially accountable? The case of Faculty of Medicine, Suez Canal University

BACKGROUND

Faculty of Medicine, Suez Canal University (FOM/SCU) was established as community oriented school with innovative educational strategies. Social accountability represents the commitment of the medical school towards the community it serves.

AIMS

To assess FOM/SCU compliance to social accountability using the "Conceptualization, Production, Usability" (CPU) model.

METHODS

FOM/SCU's practice was reviewed against CPU model parameters. CPU consists of three domains, 11 sections and 31 parameters. Data were collected through unstructured interviews with the main stakeholders and documents review since 2005 to 2013.

RESULTS

FOM/SCU shows general compliance to the three domains of the CPU. Very good compliance was shown to the "P" domain of the model through FOM/SCU's innovative educational system, students and faculty members. More work is needed on the "C" and "U" domains.

CONCLUSION

FOM/SCU complies with many parameters of the CPU model; however, more work should be accomplished to comply with some items in the C and U domains so that FOM/SCU can be recognized as a proactive socially accountable school.

The social accountability of medical schools and its indicators

CONTEXT

There is growing interest worldwide in social accountability for medical and other health professional schools. Attempts have been made to apply the concept primarily to educational reform initiatives with limited concern towards transforming an entire institution to commit and assess its education, research and service delivery missions to better meet priority health needs in society for an efficient, equitable an sustainable health system.

METHODS

In this paper, we clarify the concept of social accountability in relation to responsibility and responsiveness by providing practical examples of its application; and we expand on a previously described conceptual model of social accountability (the CPU model), by further delineating the parameters composing the model and providing examples on how to translate them into meaningful indicators.

DISCUSSION

The clarification of concepts of social responsibility, responsiveness and accountability and the examples provided in designing indicators may help medical schools and other health professional schools in crafting their own benchmarks to assess progress towards social accountability within the context of their particular environment.

Seeking impact of medical schools on health: meeting the challenges of social accountability

CONTEXT

The acquisition of sums of knowledge and mastery of sophisticated technologies by medical graduates is insufficient for their responsibilities to recognise and adapt to people's evolving needs.

RESPONSE

A Global Consensus on Social Accountability for Medical Schools brought together 130 organisations and individuals from around the world with responsibility for health education, professional regulation and policy making to participate for 8 months in a three-round Delphi process leading to a 3-day consensus development conference which included weighted representation from all regions of the world. The resulting Consensus reflects agreement on 10 strategic directions to enable a medical school to be socially accountable.

RESULTS

The list of 10 directions embraces a system-wide scope from identification of health needs to verification of the effects of medical schools on those needs, all driven by the quest for positive impact on peoples' health status. This includes an understanding of the social context, an identification of health challenges and needs and the creation of relationships to act efficiently (directions 1 and 2). Within the spectrum of the health workforce required to address health needs, the anticipated role and competences of the doctor are described (direction 3) serving as a guide to the education strategy (direction 4), which the medical school is called to implement along with consistent research and service strategies (direction 5). Standards are required to steer the institution towards a high level of excellence (directions 6 and 7), which national authorities need to recognise (direction 8). While social accountability is a universal value (direction 9), local societies will be the ultimate appraisers of the achievements of the school and its graduates (direction 10).

Combatendo as DCNT: uma abordagem diferente é necessária*

A “Aliança DCNT” (“NCD Alliance”)1 visa colocar as doenças crônicas não transmissíveis (DCNT) na agenda global de saúde, a fim de enfrentar a chamada “crise das DCNT”. Melhorar os indicadores de morbidade e mortalidade em 2015 dependerá, em grande medida, da prevenção e controle das DCNT, especialmente nos países em desenvolvimento2. *Reprinted with permission from Elsevier (The Lancet, 2011, 6 September 2011, online first) - Reprodução autorizada do original em inglês, publicado no periódico The Lancet, detentor dos copyrights:http://dx.doi.org/10.1016/S0140-6736(11)61135-5

[Global consensus on social accountability of medical schools]

A collaborative research project on the social accountability of medical schools based on the Delphi method was conducted by an international reference group composed of 130 representatives of the main associations of medical schools and medical education organizations throughout the world, in addition to experts invited to take part in a personal capacity. The project ended with a conference held in South Africa overseen by an independent adjudicator who was not an expert in the field. The event resulted in the unanimous adoption of a document entitled ?Global consensus on social accountability of medical schools'. The document emphases the importance of improving the capacity of medical schools to respond to the needs and challenges of health care for citizens and society in general, in line with the core values of quality, equity, relevance and effectiveness. The implications for reconsidering quality practices and for reviewing accreditation and evaluation criteria are presented.

Medical schools in sub-Saharan Africa

Small numbers of graduates from few medical schools, and emigration of graduates to other countries, contribute to low physician presence in sub-Saharan Africa. The Sub-Saharan African Medical School Study examined the challenges, innovations, and emerging trends in medical education in the region. We identified 168 medical schools; of the 146 surveyed, 105 (72%) responded. Findings from the study showed that countries are prioritising medical education scale-up as part of health-system strengthening, and we identified many innovations in premedical preparation, team-based education, and creative use of scarce research support. The study also drew attention to ubiquitous faculty shortages in basic and clinical sciences, weak physical infrastructure, and little use of external accreditation. Patterns recorded include the growth of private medical schools, community-based education, and international partnerships, and the benefit of research for faculty development. Ten recommendations provide guidance for efforts to strengthen medical education in sub-Saharan Africa.

Social accountability: the extra leap to excellence for educational institutions

More than ever are we facing the challenge of providing evidence that what we do responds to priority health needs and challenges of the ones we intend to serve: patients, citizens, families, communities and the nation at large. Which are those health needs and challenges? Who defines them? How do medical schools organize themselves to address them through their education, research and service delivery functions? Principles of social accountability call for an explicit three-tier engagement: identification of current and prospective social needs and challenges, adaptation of school's programmes to meet them and verification that anticipated effects have benefited society. Measurement tools need to be designed and tested to steer development in this direction, particularly to establish a meaningful relationship between inputs, processes, outputs and impact on health. The Global Consensus on Social Accountability of Medical Schools provides a unique opportunity to foster collaborative research and development in an area of great significance for the future of medical education.

Social accountability and accreditation: a new frontier for educational institutions

CONTEXT

An association with excellence should be reserved for educational institutions which verify that their actions make a difference to people's well-being. The graduates they produce should not only possess all of the competencies desirable to improve the health of citizens and society, but should also use them in their professional practice. Four principles enunciated by the World Health Organization refer to the type of health care to which people have a right, from both an individual and a collective standpoint: quality, equity, relevance and effectiveness. Therefore, social, economic, cultural and environmental determinants of health must guide the strategic development of an educational institution.

DISCUSSION

Social responsibility implies accountability to society for actions intended to serve it. In the health field, social accountability involves a commitment to respond as best as possible to the priority health needs of citizens and society. An educational institution should verify its impact on society by following basic principles of quality, equity, relevance and effectiveness, and by active participation in health system development. Its social accountability should be measured in three interdependent domains concerning health personnel: conceptualisation, production and utilisability. An educational institution that fully assumes the position of a responsible partner in the health care system and is dedicated to the public interest deserves a label of excellence.

CONCLUSIONS

As globalisation is reassessed for its social impact, societies will seek to justify their investments with more solid evidence of their impact on the public good. Medical schools should be prepared to be judged accordingly. There is an urgent need to foster the adaptation of accreditation standards and norms that reflect social accountability. Only then can educational institutions be measured and rewarded for their real capacity to meet the pressing health care needs of society.

Building a socially accountable health professions school: towards unity for health

In many countries, health systems suffer from fragmentation as different health activities conducted by different stakeholders are poorly coordinated, resulting in a mitigated performance to improve quality, equity, relevance and cost-effectiveness in health care. The impact on health would be enhanced if main stakeholders such as health professional schools, service organizations, professional associations, health policy bodies and the general public shared a common vision on how to best meet people's priority health needs. An approach initiated by WHO in 1999 and developed by The Network: Towards Unity for Health endeavours to create a unity of purpose and action among these stakeholders. This article comments on challenges and opportunities in implementing this approach whose pillars are integration and partnerships. The conditions for each stakeholder to become more socially accountable and the role of a teacher, researcher, manager or community representative in contributing to this process are discussed.

[Congenital hyperinsulinism in 15 infants, 1981-1999; experiences and new insights]

OBJECTIVE

To report on a retrospective study into the diagnostics and treatment of infants with congenital hyperinsulinism (CHI; persistent hyperinsulinemic hypoglycaemia).

DESIGN

Retrospective and descriptive.

METHOD

The study included all 15 patients diagnosed with CHI at the St Radboud University Medical Centre, the Netherlands, from 1981 until 1999. Data gathered by systematically searching case-notes included: presentation, clinical admission, laboratory results, treatment and follow-up.

RESULTS

Four of the 15 infants were macrosomatic; 12 (80%) were presented within 4 days of birth, and the rest after the age of 5 months. Their symptoms were partially aspecific (feeding poorly, lethargy) and partially clear, corresponding to neuroglycopaenia (jitteryness, hypotonia). Nine infants experienced convulsions. The amount of glucose that had to be administered to achieve normoglycaemia (average: 16.9 mg/kg/min) was far above the basal requirement of 4-8 mg/kg/min. Ketone serum and free fatty acid values were lowered during a hypoglycaemic episode, hyperinsulinism was detected after repeated measurements. Five infants responded well to treatment with diazoxide. Ten children underwent subtotal pancreatectomy after which 4 remained normoglycaemic. Three of the 10 children who underwent surgery developed an exocrine pancreas dysfunction. We did not systematically examine neuropsychological development, but in 5 of the 15 children this was clearly disturbed.

[World Health Organization strategies "Towards Unity for Health" and the social responsibility of medical schools]

One may wonder why multiple endeavours conducted worldwide over the last five decades to reform health systems have not achieved their expected outcomes. In light of increasing fragmentation, the current health system must be substituted by a true systems vision along with political will to create a unity of action between the five main stakeholders, namely: policy-makers, health care service managers, professionals and professional associations, academic institutions including medical schools, and civil society. Such synergy can only be established if the partners share the same commitment to core values such as quality, equity, relevance and cost-effectiveness in the health care field. Through its functions of providing education, training, research, and services, the medical school has the potential to induce reflection and stimulate action leading to a more coherent, effective, and equitable health system and policies.

Exercise intolerance, muscle pain and lactic acidaemia associated with a 7497G>A mutation in the tRNASer(UCN) gene

A 13-year-old girl with non-familial exercise intolerance, muscle pain and lactic acidaemia underwent a muscle biopsy for suspected mitochondrial disease. Muscle morphology showed 25% ragged-red fibres and 80% COX-negative staining. Enzymatic activities of mitochondrially co-encoded respiratory chain enzymes (complexes I, III, and IV) were decreased in muscle but normal in cultured skin fibroblasts. mtDNA analysis revealed the presence of the 7497G>A mutation in the tRNASer(UCN) gene, homoplasmic in skeletal muscle and 90% in leukocytes. Analysis of the mother's mtDNA showed 10% heteroplasmy in blood. It may be concluded that the 7497G>A mutation is associated with a muscle-only disease presentation for which high levels of mutated mtDNA are required. Exercise intolerance and muscle pain in otherwise normal children warrants further mitochondrial evaluation.

Clinical heterogeneity in patients with mutations in the NDUFS4 gene of mitochondrial complex I

A comparison of the clinical presentation, disease course and results of laboratory and imaging studies of all patients so far published with a NDUFS4 mutation are presented. This reveals marked clinical heterogeneity, even in patients with the same genotype.

Quest for social accountability: experiences of a new health sciences university in Nepal

CONTEXT

B.P. Koirala Institute of Health Sciences (BPKIHS), a new Health Sciences University in Nepal has taken several steps to respond to the societal needs and has adopted an integrated, partially problem based and community oriented curriculum.

OBJECTIVE

The objective of this study was to measure the school's achievements in responding to societal needs.

METHODOLOGY

A descriptive cross sectional questionnaire survey (N = 46) of the administrators, faculty, students/residents and the community. The questionnaire included statements on relevance, quality, cost effectiveness and equity in the education, service and research domains of a medical school. The data were analyzed by using WINKS 4.5, a statistical package for Windows.

RESULTS

The responders satisfactorily rated BPKIHS. The mean rating (mean 3.11, SD = 1.06) was more than the satisfactory score (3). The responders were satisfied with the education (Mean = 3.26, SD = 1.06) and research (Mean = 3.12, SD = 1.10) but were less satisfied with the service domain (Mean = 2.94, SD = 0.98). The majority believed that the service is based on health care priorities (72%), and includes primary care (80%). A fair proportion felt the need for improvements in quality of care (50%) and cost effectiveness of care (46%). In general the faculty and administrators groups were more satisfied than the community and students/residents groups.

CONCLUSION

The study was useful in identifying the school's strengths as well as weaknesses in responding to the societal needs.

Adapting health care institutions and medical schools to societies' needs

Although societies and the priorities of stakeholders within them differ, four universal values regarding health care exist: quality, equity, relevance, and cost-effectiveness. The first two of these values can be viewed as poles of "the dream axis" and the second two as poles of "the reality axis." Medical schools and other stakeholders can pursue optimal patterns of health care most effectively through partnerships with one another. With regard to improving the health care system, medical schools can be characterized as neutral, reactive, or proactive. A socially responsible medical school perceives the needs of society and reacts accordingly, and a socially accountable school also consults society about priorities and provides evidence of impact of its deeds. A grid for assessing the social accountability of medical schools has been developed. With this grid, a school's activities in education, research, and service are evaluated relative to the four universal values of quality, equity, relevance, and cost-effectiveness of health care; activities also are characterized as "planning," "doing," or "impacting." Assessment can promote greater social accountability of medical schools.

Prospects for change in medical education in the twenty-first century

With Health for All as a social goal and a reference point, medical schools must create new alliances within the health sector and with other sectors bearing on health. The future role and responsibility of the medical school should reflect the likely essential features of the future health system and the aptitudes that medical practitioners will have to possess. Medical schools should be encouraged not only to shape their educational programs accordingly, but also to devote energy and resources to the considerable task of creating opportunities for this new practitioner. Quality in medical education results from a coordinated effort to ensure relevance and efficiency in the education of future doctors and to ensure these doctors' optimal fit in society. Implicit in the notion of quality is a special consideration for social accountability. A medical school shows social accountability through its commitment to addressing issues, or helping solve problems, identified jointly with society as priorities for both the present and the longer term, in the expectation that the medical school's action will benefit in part the local community and in part the country as a whole or the international community. Indicators of quality in medical education, as well as measurement tools, must be developed and tested in various sociocultural contexts. A taxonomy to assess the social accountability of medical schools is proposed.