Social accountability of

medical schools

The primary goal of undergraduate medical education (UME) :

to create a doctor who is broadly educated across the key competencies of medicine and who has the knowledge and clinical skills to

enter graduate training

clinical productivity

research

resident

education

It is difficult to accomplish this goal :

In traditional fragmented and highly specialized clinical environments in which medical student education competes with:

oOver the years, the WHO and other organizations have advocated

that doctors consciously adopt new roles to become more active in

health development, particularly through primary health care

oThey have insisted on the need for new physicians to acquire

new competencies:?????

Care provider

Decision-maker

CommunicatorCommunity

leader

Manager

However, too few medical schools have acted to recast their educational programs accordingly

As a result, a mismatch has persisted between what is being taught and learned in medical schools and what is expected from future doctors in their health systems

Traditional medical education in high- and low-income countries

emphasize :

Biomedical disease-oriented model

alone does not fully address today’s public health need, and often

lacks firm social mandates

Definition of

Social accountability of

medical schools

Educa

tion re

sear

ch

serv

ice

Priority health

concerns of the

community

governments

health care organizations

health professionals

the public

Priority health

concerns of the

community

Relevance

• The degree to which the most important problems are tackled first

Quality

• use evidence-based data and appropriate technology to deliver comprehensive health care to individuals and populations, taking into account their social, cultural and consumer expectations

Cost-

effectiveness:

• have the greatest positive impact on the health of a society while making the best use of its resources

Equity

•Equity, which is central to a socially accountable health care system

•striving towards making high-quality health care available to all.

values of social accountability

Criteria to determine the social accountability of a medical school

The extent to which the school’s guiding principles are community orientated

The emphasis placed in the curriculum on concepts and knowledge of what constitutes a community and a population, how to measure and cope with health needs and how to take proper account of the cultural and social background

The extent to which community-based learning forms part of the curriculum

The degree of community involvement in the training program

The organizational linkages between the school or program and the health services system

What major initiatives should a medical

school take to be recognized as

“socially accountable”?

First:

The school must :

provide ample and appropriate learning opportunities for medical students to grasp the complexity of socio-economic determinants in health

integrate the biomedical aspects of diseases into a holistic approach to health

Second:

The school must :

Share responsibility for ensuring equitable and quality health services delivery to an entire population within a well defined geographical area

In this context, public health and health service research should be declared priority investments to experiment and develop best health practices for involving future graduates.

Third:

the school must :

Recognize social accountability as a mark of academic excellence, promoting relevant evaluation and accreditation standards and mechanisms

New standards should be adopted highlighting the school’s capacity to anticipate the profile, mix, and number of health professionals needed to meet society’s present and future priority health concerns, and its ability to help create relevant work environments for its graduates

Moreover, the school’s performance should be assessed by a group composed partly by academic staff and partly by representatives of the society the school intends to serve.

A number of innovative medical education

programs, building on social accountability

principles, have been established to address

priority health needs of their communities and

health systems

Networking Innovative Socially Accountable

Medical Education Programs

In 2007, the Global Health Education Consortium (GHEC) received

funding to facilitate the development of a network of socially

accountable medical schools whose express mandate is to train

physicians for addressing health needs in resource-constrained

settings.

GHEC identified eight medical education programs of varying sizes

and operating in high- and low-income countries, whose mission is to

train doctors for service in underserved areas

These schools are:

o The Latin American School of Medicine in Cuba (ELAM)

o The Comprehensive Community Physician Training Program in Venezuela (CCPTP)

o The Northern Ontario School of Medicine in Canada (NOSM)

o The Faculty of Health Sciences at Walter Sisulu University in South Africa (WSU)

o Flinders University School of Medicine (FLINDERS) and James Cook Faculty of Medicine, Health and Molecular Sciences (JCU) in Australia

oAteneo de Zamboanga University School of Medicine (ADZU) and the University of Philippines School of Health Sciences (SHS) in the Philippines

In late 2008 : THE net was created:

To increase understanding globally of how schools can produce health

and health workforce outcomes that improve health equity and health

system performance and how to measure progress towards these goals

It is a global network of socially accountable schools sharing a core

commitment to achieving equity in health care and health outcomes

through quality education, service and action-oriented research

responsive to the needs of communities and health care systems.

Health and social needs of targeted communities guide

education, research and service programs

Students recruited from the communities with the greatest

health care needs

Programs are located within or in close proximity to the communities they serve

Much of the learning takes place in the community instead of predominantly in university

and hospital settings

Curriculum integrates basic and clinical sciences with

population health and social sciences; and early clinical

contact increases the relevance and value of theoretical

learning

Pedagogical methodologies are student-centered, problem and service-based and supported by information technology

Community-based practitioners are recruited and

trained as teachers and mentors

Partnering with health system actors to produce locally

relevant competencies

Faculty and programs emphasize and model

commitment to public service

Core Principles

FLINDERS

Established in 1975

Parallel Rural Community Curriculum established in 1997

PRCC students are placed in rural general practice, with medicine,

surgery, pediatrics, obstetrics and gynecology and specialties integrated

throughout the year

Program has government support with university- local service

provider and community partnerships

WSU

Established in 1985 as a rural medical school, reformed curriculum in 1992

Leading problem-based learning and community-based medical education program in Africa

Learning activities occur in rural provincial health system and through community partnerships program

ADZU

Established in 1994

Problem- and competency-based learning model with strong locally oriented public health and behavioral perspectives; includes working on clinical problems and on the method of problem analysis itself

Service learning model—students provide services from the 1st year, including implementing inter sectorial health development programs.

Students spend close to 50% of their time in the community

ELAM

Established in 1999

Large scale, currently training 9,000 students with 6000 graduates

Recruit students from underserved communities in Latin America-Africa-North America

Scholarships offered for study in Cuba, including training in Cuban communities

Last year of six-year curriculum in internship in country (community) of origin

JCU

Established in 2000

Innovative medical curriculum with a focus on rural & remote health, indigenous health & tropical medicine

Clinical experience in the rural and remote context at an early stage

CCPTP

Established in 2005

Large scale, currently training 23,000

All learning takes place in the communities students are from or in close proximity

Faculty are community-based physicians, most with masters degree in medical education

The faculty in collaboration with underserved communities is simultaneously developing and integrating medical education program into primary care infrastructure

NOSM

Established in 2005

Smaller scale and rural

Up 40% of distributed learning takes places in urban, rural and aboriginal communities in the North, facilitated by trained practitioners and faculties miles away from students

Highly integrated curriculum with no courses by discipline, instead organized around five themes

e-curriculum allows students posted in different communities to work as teams and participate in virtual academic rounds

SHS

Community- and competency-based step ladder curriculum Integrates training of health workers, midwives, nurses and physicians in a single, sequential, and continuous curriculum 

In conclusion:

Simply placing students in a community setting as part of the curriculum is not a sufficient response to the challenge of social accountability in medical education.

A comprehensive strategy would include education, clinical service and research.

The education component would include a continuum of community-related activities throughout undergraduate education

The services component would include clinical outreach activities as well as a commitment to producing the appropriate mix of generalists and specialists to serve the whole community.

Finally, the research component would involve university faculty, members of the community and program funders in addressing research questions formulated in consultation with the community

community-based education: (WHO , 1987)

•learning activities that take place within the community in which

not only students but also teachers and patients are actively engaged

throughout the educational experience

• Community-based education can be implemented wherever people

live, in rural, suburban or urban areas

rationale behind community-oriented medical education (Habbick & Leeder) :

•creating more appropriate knowledge, skills and attitudes

•Deeper understanding of range of health, illness, and the workings of health and social services

•Deeper understanding of the contribution of social and environmental factors to the causation and prevention of illness

•A more patient-oriented perspective

•making better use of the expertise and availability of staff and patients who are in primary care settings

•enhancing multidisciplinary working

•Broader range of learning opportunities

•Increasing recruitment into primary care and generalist specialties.

Collectively, THE net enables sharing, peer support

and collaboration while working with stakeholders to

develop and disseminate evidence, challenge

assumptions, set standards and promote socially

accountable medical education