| o Review |
(Dr. Boelen is chief medical officer, Educational Development of Human Resources for Health, World Health Organization, Geneva, Switzerland.)
Abstract
The
Dream and Reality Axes
Partnership
for Progress
Optimal
Organization Patterns of Care
Medical
Schools on the Health Chessboard
Social
Responsiveness and Social Accountability
Boosting
Social Accountability Through Coalitions
Improving
By Assessing
Concluding
Comment
References
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.
Responding adequately to people's health needs and expectations means meeting the needs and expectations of interest groups that have different opinions of what constitutes an adequate response. Whereas consumers primarily want high-quality health service readily available and in adequate quantity, health professionals want to develop their areas of expertise and exercise independent judgment in providing the best possible care, and health care policy-makers and organizers want cost-effective care for all citizens. This situation is even more challenging because the wealth of data available enables each group to be more specific in its demands, confront standpoints more objectively, and negotiate compromises on more reliable and quantifiable grounds.
Despite their varied priorities, all groups can be assumed to agree that everyone in society should enjoy the highest possible health status. All nations have largely endorsed the health-for-all goal articulated by the World Health Organization (WHO) in 1978, and national health authorities have consistently supported primary health care as the main strategy for making steady progress toward this goal.1,2 To be translated sustainably into practical terms, these revolutionary commitments required most current health systems to undergo major reorientation. Two decades later, this reorientation has not occurred to the extent expected. Rather, disquieting evidence exists everywhere of increasing inequities and new pockets of poverty and ill health.3One major observation is that health systems have not been designed flexibly enough to evolve toward the satisfaction of all stakeholders and that optimal organizational patterns in health care delivery have yet to be invented to ensure full compliance with the values on which health services should be based: quality, equity, relevance, and cost-effectiveness.
The quest for quality is the search for the satisfaction people want in the management of their health problems. Although criteria for quality vary with the levels of social and cultural development and with the availability of skillful staff and advanced technologies, beneficiaries of health care invariably expect their problems and concerns to be addressed with humanity, respect, and personal attention through a comprehensive array of services for the fulfillment of their legitimate aspiration to well-being.
In any context, people's expectations evolve
with their capacity to understand the determinants of health and ill health
and their informed judgment of what may suit them best in particular circumstances.
The concept of quality is also shaped by the health professions in setting
standards
and norms of good practice, which also
evolve with the advent of more sensitive evaluation measurements and procedures
and new health technologies. Policies for quality improvement have developed
worldwide through the activism of both health care beneficiaries and providers.
Competition among health care providers also spurs this development.
As excellence in health care cannot be the privilege of a few, the trend for increased action toward improved equity in health care and health status is most reassuring.4 But good intentions for making health benefits available to everyone have yet to be implemented satisfactorily. Obvious disparitiesexist among nations as well as within each nation.
The goal is to eliminate discrimination based on race, gender, religion, culture, or socioeconomic status and to install mechanisms by which everyone in a community can be guaranteed access to a minimum set of services to ensure a productive life. This right should be accompanied by another right - a l s o considered a duty - for all to be empowered to protect and promote their own health by being adequately informed about health risks and opportunities and healthy lifestyles.The mounting sensitivity to equity issues in health goes beyond ad hoc attention to the poor and uneducated to embrace society at large because marginalization from the mainstream of health services can affect such subgroups as the homeless, the jobless, and those who are alone. These are groups in which any of us could find ourselves. Because the circumstances of life can bring anyone to the brink of despair, society should be vigilant and prepared to mobilize solidarity to help all those who are at risk of losing their social rights, including the right to health.
Simultaneously achieving the goals of quality
and equity is a "dream" in the sense that it .is highly desired. For critics,
providing the best possible service to everyone in society is a "dream,"
or impossible, as quality and equity are supported by forces working in
opposite directions (Figure 1).
Figure 1. The "dream" axis.
Such critics argue that to some extent the energy and resources invested to improve quality would be detrimental to the cause of equity.In some situations, however, the development of high quality products or procedures affects the health of the masses. Examples include the production of effective vaccines and the introduction of educational or preventive programs. Obviously, in such situations, sophisticated research and development efforts were designed to benefit the multitudes.
Aspiring simultaneously to both quality and equity may seem problematic because quality is seen as referring to a commitment to spare no effort or cost to restore or protect the health of individuals. On the one hand, with rising costs of health care and constrained national health budgets, the "impossible dream" theory gains strength with the increasing evidence that if more sophisticated assistance is given to some, other and larger groups will be denied basic health services.
On the other hand, proponents of the "possible
dream" theory argue that a point of equilibrium can be reached on the "dream
axis" between the forces supporting attention to individuals and those
supporting attention to the masses if certain conditions are fulfilled,
namely the quest for relevance and cost-effectiveness. While the "dream
axis" represents the aspiration of the fulfillment of all expectations
for all, the "reality axis" reminds us of the necessary use of rules and
negotiations to realize our dream (Figure 2).
Figure 2. The "dream" and "reality"
axes.
Relevance means that the most important problems must be tackled first. Criteria for relevance necessarily vary with epidemiology and the vulnerability of people and the priorities of different subgroups. If the principle of relevance is applied, both quality and equity can be provided if resources are preferentially used to address the most important health concerns or to direct efforts toward individuals and groups in greatest need.Controversies arise when priority setting is equated with reduction of health care services by those who either are denied certain categories of services that health authorities consider less important or have conditions imposed on them if they persist in their wish to obtain the desired services. Efforts to justify the priority setting quantitatively will not remove the different qualitative appreciation of priorities, and negotiation will always be needed to reach a consensus or an acceptable compromise. While this rationale is consistent with a national health system aiming at universal coverage with taxpayers' funds, it will variably apply where there is a health insurance scheme, a managed care organization, or fee-for-service arrangements.The value of cost-effectiveness is amply recognized at times of budget restriction, as is any innovative measure to make the best use of available resources in delivering a given service. However, the growing desire for more transparency and increasingly evidence-based practices may have troublesome implications for some and create tensions in the health care system. With the evidence that some procedures can be done with equal quality by less educated and less costly health staff, critical reviews are being encouraged to allocate or reallocate tasks and responsibilities optimally among the health professions. Consequently, shifts of responsibilities can be envisaged between generalists and specialists, between doctors and nurses, and between nurses and allied health personnel and social workers. Collaboration among the health professions is increasingly being influenced by principles of negotiated transfer of responsibilities, substitution, complementarity, and competition.5Each value - quality, equity, relevance and cost-effectiveness - gives rise to specific streams of research and development in health systems across the globe. Progress toward compliance with each such value requires a clear definition of its meaning and the specification of norms, indicators, and criteria. This by itself is a challenge, particularly as the definitions of these values continue to evolve and require unanimity of views among the main stakeholders. However, a bigger challenge for a health system is to strike a satisfactory balance in trying to comply with the four values.
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PARTNERSHIP FOR
PROGRESS
Technically appropriate and socially acceptable
compromises must be sought, a process that requires from the principal
stakeholders a shared vision and efficient collaboration. Otherwise, a
balanced approach toward the values outlined in the "dream and reality
axes" would vanish, as each stakeholder naturally tends to favor one value
at the expense of others. Politicians in need of voters' support, for instance,
may be tempted to exploit preferentially the "equity" direction; economists
may favor "cost-effectiveness* at the expense of social and humanitarian
aspects; some health professions may choose to support patients by advocating
unlimited access to costly technologies under the cover of the "quality"
direction.
Figure 3. Health for All.
Stakeholders as different as health policymakers, health managers, health care providers, academics in the health professions, and consumers increasingly realize that protection of their turf and defense of their sectorial privileges and prerogatives cannot serve as foundations for sound development of the health system. Rather, efforts to improve the overall performance of the health system must rest on contributions from a variety of talents to a common agenda for action. These efforts must go beyond those of cost containment or financial management to enable the system not only to keep its usual commitment to service delivery but also to strive comprehensively for quality, equity, relevance, and cost-effectiveness. The tasks certainly require partnership among concerned organizations, institutions, and professional groups.
The example of a search for optimal use of human resources illustrates the benefit of such partnership. It might be expected that optimal use of human resources would result from the summing of circumstances and actions such as a clearly defined mandate and an operational model of health settings in which future health personnel will function, with properly defined roles and scopes of responsibilities of health personnel. adherence to guidelines for good practice, appropriate working conditions and motivation at work, and an efficient educational system. Each action is influenced by others. It is therefore important to understand the interrelationships between organizations or institutions that carry the major responsibility in human resources development and to encourage productive interaction. Figure 3 points out the desirable network of relationships between changes in health care, medical practice, and medical education to make steady progress toward a commonly agreed-on goal, in this case the WHO goal of health for a1l.6,7Although the change process can be initiated at various entry points, there is a prevailing thought that through the strength of educational programs alone, changes in behavior will occur and endure. However, changes introduced in medical education do not necessarily induce sustainable changes in medical practice, and thus in turn do not have exclusive influence on health care and health status. In reality, more important determinants, over which educational planners have no control, affect practice.8 For instance, improved pay and better job opportunities are likely to be more effective in attracting doctors to family practice than the most exciting educational exposure to this discipline.Specific dynamics are at work in health care organization, professional practice, and academic institutions, and different sets of factors influence them. The ideal situation is one in which changes in the three components are coordinated. In the case of promoting family medicine, for instance, we might envision the development of a government policy to recognize family medicine as a foundation for health care organization, provision of professional and material incentives to practice as a family physician, and development by academic institutions of research and education in order to promote family medicine as a respected discipline.9Such a strategic approach is supported by the WHO Global Strategy for "changing medical education and medical practice for health for all" to implement resolution WHA48.8, through which the World Health Assembly recommended promoting "coordinated efforts by health authorities, professional associations and medical schools to study and implement new patterns of practice and working conditions that would better enable general practitioners to identify and to respond to the health needs of the people they serve."10-12 .A similar rationale has been applied in several partnership approaches in different countries by international network13 or foundations,14,15 involving, in various combinations, medical schools or universities, health services, local governments, and communities. These experiences have generally proven useful in identifying circumstances under which the performance of each partner could be improved and in pointing out how efficient interaction can improve such performance.
For instance, the following comments and recommendations have been heard worldwide:"What have we done to ensure that graduates will be employed to do what they have been trained for?""How useful are the incentives proposed by health care organizations in influencing career choices?""How efficiently has the potential of academic institutions been used to influence policies and design innovative health care delivery systems?""If health professionals are expected to work in multi-professional teams, why are they not educated that way?'"If quality, equity, relevance, and cost-effectiveness are basic health goals in any society, what can influence the main stakeholders in making specific readjustments to better serve these goals?Questions such as these illustrate the scope of actions for relevant responses to societies' needs that the partnership approach is likely to spur. Awareness of the richness of interaction and the intricacy of causes and effects calls not only for a shared vision among partners of what the ideal healthsystem is but a firm commitment for joint action and mutually supportive working arrangements. The task is vast and complex.One main challenge is to overcome a common contradictory situation in countries whereby declarations of good intentions- intended to facilitate the convergence of efforts from different stakeholders in the perspective of a holistic approach - are neutralized by growing incentives for individual work, competition, and protection of privileges. The evolution toward an efficient partnership among stakeholders motivated by different agendas would be facilitated if optimal organizational patterns of care could attract their common interest by outlining the new opportunities that such patterns may offer to them, as well as the compromises to which they must consent in a partnership approach.
OPTIMAL ORGANIZATIONAL
PATTERNS OF CARE
The growing fragmentation in the health care delivery system, as exemplified by the existence of important divisions between curative and preventive care, generalists and specialists, health care and social protection, individual care and population-based care, and public and private services, works against the emergence of optimal responses to the challenges for improved quality, equity, relevance, and cost-effectiveness. This is a globally relevant observation because of similar factors at work worldwide: the propensity for an analytic approach to problem solving based on the extensive use of science and technology at the expense of a holistic approach based on epidemiologic and social sciences; paradigms biased toward action against disease rather than action for health; a configuration of service and care too often tailored to the convenience of the health professions rather than to the public's needs and expectations; an empirical division of labor among health care providers and between health care providers and consumers; traditions and beliefs; and above all, the inherent complexity of encompassing the wide spectrum of health and ill health determinants into appropriate and coherent packages. The wave of cost-containment measures and the frantic introduction of managed-care schemes and competition within the health sector carry risks of further fragmentation, turf protection, duplication of work, and waste of resources at the expense of quality, equity, and optimal overall management of the health system.
The thirst for more appropriate development of the health system has awakened the need to reduce fragmentation and sub-optimal management of health resources and build momentum for coordinated action, particularly at the primary care level. The assumption is that such coordination could be strongly stimulated by creating efficient cooperative links between medicine and public health, or, in other words, between individual and population-based health services.
Although these two areas do not always operate in strict isolation from each other, too often individual and population-based health services are conducted in relative ignorance of each other, compete for similar resources, and lead to separate institutional careers using competing paradigms of work. We may reasonably assume that if optimal organizational patterns of care at the primary level were developed such that the main inputs from medical and public health services were jointly planned and managed with the aim of best serving people's well-being in their living environments, a major fracture in the health system would be healed, which would open the path for further progress toward a more unified approach in health care, with landmarks such as the following:
The following are proposed features of an optimal organizational pattern of care:
Territoriality and reference population. Ideally, jurisdiction for health should be territory-bound, consistent with the mandate of a basic administrative unit (district, town, or village) enjoying decentralized authority to coordinate the, delivery of a broad range of services. The population to be served should be known demographically, sociologically, and epidemiologically. If coverage is universal, the reference or target population is the total population living in this territory. Otherwise, depending on the features of the health system, several reference populations may coexist in a given territory: enrollees in health programs, patient populations, vulnerable subgroups, and so forth. Action should be coordinated to optimize effects on health care and health status.
Primary care orientation. Efficient delivery of primary health care should be a recognized priority, and it should be seen as the foundation for health system development. The first contact of consumers should be with primary care providers working in multidisciplinary teams with the view of providing adequate responses to most health concerns and problems. Priority health issues should be assessed and reassessed regularly, and secondary and tertiary care should be delivered in a manner consistent with a primary care orientation.
Dual concern for individuals and populations. A wide spectrum of health services targeting either individuals or groups and populations should be planned, organized, and monitored to complement one another. The goal is to improve the health care and health status of everyone living in a given territory or belonging to a particular health scheme.
Comprehensive health information management. Within given confines and with the requirement that confidentiality be protected, a process should exist by which health data from different sources (patient records, epidemiologic data sources, and social and environmental data sources) are collected, merged, and analyzed to assess health status and health risks and the use of services, in order to make informed decisions regarding the most appropriate ways to improve quality, equity, relevance, and cost-effectiveness in health care. Consumers should have easy access to health information to empower them to take greater responsibility for their own health and help them decide on the ranges of services most suitable to their needs.
Operational model for integration. A model describing how a given health care setting can comply optimally with the principles stated above should be developed. It should outline how the various health services should link with each other, how resources should be allocated, and how the division of labor among health care providers should be decided on. The model should also suggest ways to assess and improve the overall performance of the health setting with regard to the goals of quality, equity, relevance, and cost-effectiveness.
Support for sustainability. To be adopted, succeed, and be sustained, optimal patterns of care require several conditions, including clear health policy orientations, awareness by stakeholders of new and attractive opportunities for recognition and growth, research and development to adapt patterns to different socioeconomic contexts, preparation of health professionals through adequate educational programs, and full support by the community of beneficiaries. In this context, what is the possible contribution of medical schools?
MEDICAL SCHOOLS
ON THE HEALTH CHESSBOARD
Medical schools, like other stakeholders, cannot stay indifferent to important readjustments in the health system. Their contribution will depend on their talents and resources, as well as on their ability to build productive partnerships with other forces in society. Their potential is variably used, however; we can categorize the degree of their social responsiveness as follows.
Neutrality. In this common situation, medical schools perform their education, research, and service delivery functions with little concern for suiting the changing needs of individuals, families, and the community at large. Under the cover of academic freedom and search for excellence, they pursue scientific and technologic objectives in relative ignorance of the most prevalent and urgent health issues. These objectives are chosen with little consultation outside academic circles. Work is assessed mainly by peers and has little direct and immediate relevance to people living in the surrounding community.
In the developing world, this attitude has led to painful situations. In one case, a medical school proudly announced its progress in sophisticated brain surgery while its infectious diseases department could not prevent deaths from cholera due to contamination of water from a well about 200 meters from the operating room. In many developing countries, medical schools have been established according to models in the industrialized world; too many have not reviewed their mandate to adapt to their environment. Sometimes they remain more conservative than the mother institution. Strikingly, in many countries, both poor or rich, poor delivery of basic health services coexists with sophisticated biomedical research. Medical schools that do not react sufficiently to such situations are labeled "ivory towers."
Reactivity. An increasing number of medical schools are aware of priority health needs in society and take the initiative in reacting responsibly. Their mandate is explicit with regard to improving people's health, facilitating universal access to health care, and contributing co meeting new challenges in the health system. An example of expression of this commitment is strong input to community health action, with staff and other resources originating either from a specialized department or, better, from several departments of the school. Such schools adapt their educational programs to better meet people's needs and expectations. Curricula are regularly assessed and updated, learning opportunities that expose students to the harsh realities of life at community level are offered early and throughout the curriculum, and students are selected from all segments of the community, particularly those most deprived. Such schools facilitate collaborative ventures with health authorities and the community in order to increase the relevance of their education, research, and outreach programs, These schools are prepared to react to people's evolving needs and to changes in the health system. Those schools that are organized to make systematic use of health status information in the community react promptly; others take longer to react and readjust.
Proactiveness. This is the category to which most medical schools should belong. It is characterized by an attitude of anticipation. Here the medical school uses its talents and resources, as well as its capacity to collaborate with other actors, to do an authoritative situation analysis of the health sector, to identify future challenges in this sector, and to help design and develop innovative approaches to meet these challenges. A comprehensive understanding of the evolution of the health care system allows a medical school to hold a more responsible position on the health care chessboard. For instance, the school's responsiveness will not be limited to implementing an ideal educational program to prepare the next generation of doctors, but will encompass action to ensure that the new breed of graduates will find a working environment consistent with the education they have received. This implies that the medical school, like any other manufacturer, studies the market for its products and contributes to creating favorable conditions for employment, consistent with society's expectation.18
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SOCIAL RESPONSIVENESS
AND SOCIAL ACCOUNTABILITY
Of these three positions, proactivity most closely approaches the concept of social responsiveness. Social responsiveness is the degree to which a medical school responds to societal needs. For instance, a socially responsive school is concerned whether its graduates perform as effectively as expected in serving society and is committed to making adjustments according to the lessons learned. It may also examine the extent to which the results of research affect priority health issues, or it may question the validity of the health services it delivers in serving as models for health care providers. In short, a socially responsive school perceives the needs of society and reacts accordingly.
The concept of social accountability goes beyond that of social responsiveness. It implies that the school consults society and jointly identifies priority health issues and expectations, and that it provides evidence that it addresses them in order to obtain short-term and longer-term benefits, in part for the local community and in part for the country as a whole or the international community.19
Medical schools should voluntarily be socially
responsible, but they should also expect society to hold them to account
for what they do, particularly if they are supported by funds from taxpayers.
Although academic freedom must be protected to allow creative minds to
open new fields of investigation without undue interference and to prepare
society to face new challenges, accountability to society should be defined
and delineated. Medical schools should take the initiative by suggesting
ways to revise their mandate in light of the evolution of society and the
health system and to readjust their scope of work accordingly. In doing
so, they will set their own framework and reference points for assessing
their social accountability and lessen any undue pressures from financing
or donor agencies or other external bodies. Social accountability can be
assessed using four essential reference points. These were described earlier
as the fundamental values on which health system development should rest:
quality, equity, relevance, and cost-effectiveness.
Domains
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A taxonomy of social accountability can be developed by defining the degrees of compliance with these values in the three basic domains of institutional responsibility: education, research, and service. Such a taxonomy can provide the basis for a "social accountability grid" (Figure 4) to assess the extent to which efforts in these three domains contribute to building a health care system that is relevant to the needs of the community or nation and provides high quality health care that is cost-effective and equitable.
The taxonomy can be further developed to
portray the evolution of the medical school toward the highest phase of
social accountability, that of affecting the health system. The expanded
grid (Figure 5) includes three phases: "planning,""doing," and "impacting."19
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The most modest commitment is the "planning" phase, in which a medical school shows that it intends to undertake socially accountable actions -by means of the content of its mission statement, or the way departments are organized, or the way resources are allocated. The "doing" phase involves more commitment: restructuring has been done, staff time has been used, resources have been spent, or relevant activities have been performed. Finally, in the "impacting" phase, the school demonstrates its contribution to important and sustainable changes in the health care system-achieved, for example, by advocating these changes among policymakers, health care organizations, the health professions, or the community of users. The chances of having significant impact are greater if partnerships are pursued with these actors from the "planning" phase on. Thus, the social accountability grid now consists of 36 cells. For each cell, general indicators can be proposed that are adaptable to the local sociopolitical context, and criteria can be provided for quantifying the degree to which the indicators have been satisfied. This grid has been examined by an international sample of medical schools and field-tested as a tool to assess, stimulate, steer, and monitor the response of medical schools to society's needs.20
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BOOSTING SOCIAL
ACCOUNTABILITY THROUGH COALITIONS
One way to improve a medical school's response
to society's needs is to facilitate the passage from intentions to deeds
and from deeds to effects. Consider, for example, the continuum of the
"planning," "doing," and "impacting" phases in the domain of education
with respect to equity
(Table 1).
Table 1
| Phases in
the domain of education with respect to equity
The "planning" phase: The curriculum is designed and updated at appropriate intervals to emphasize the provision of care to the underserved. The 'doing" phase: Throughout their education. all students and graduates are exposed to a variety of learning opportunities in which health care to the underserved is practiced. The performance of students in this activity counts in their overall evaluation. The 'impacting" phase: The medical school has taken the initiative to ensure that it has produced physicians who can maintain their skills and deliver health care to the underserved. |
Table 2
| Summing of
the "impacting" Phases in the Social Accountability Grid with Respect to
Equity
The impacting phase in education: The medical school has taken the initiative to ensure that it has produced physicians who can maintain their skills and deliver health care to the underserved. The impacting phase in research: Results of research on equity in health care delivery are disseminated and initiative is taken by the medical school to ensue that these results are considered by appropriate groups for policy development and decision making. The impacting phase in service: Based on experience and evaluation of different approaches to health service delivery, the medical school has taken the initiative to influence appropriate groups for policy development and decision making to ensure that provision of health care to the underserved is promoted and encouraged. This would come even closer to the outcome expected by society." |
The education, research, and service activities of a medical school must reinforce each other by addressing complementary facets of a common issue. For instance, the value of integrating the principles and methods of preventive medicine and public health in teaching the clinical sciences can: not be denied, but considerable value is added when medical schools complement this educational innovation by such concrete means as doing research on guidelines for good practice and recommending ways to reward good practice in routine service delivery. The combination of education, research, and service innovations in this realm is likely to have mote impact than innovations in any single realm. Likewise, for instance, if a medical school is committed to helping reduce society's burden of prevalent of re-emerging infectious diseases, it must work in partnership with other actors who influence disease control. The medical school's role in strengthening tuberculosis control is an example.21
In the more complex situation of affecting
important determinant of ill health, such as poverty and inequity, partnership
is even more important. The initiative taken by WHO and UNESCO to study
the role of universities in improving the health of the disadvantaged is
an example of faculties of medicine and health sciences seeking associations
with faculties of political and social sciences and extending collaboration
with local governments, professional associations, and communities to work
effectively and sustainably in favor of the health of the most deprived
in society. The more diversified and productive alliances a medical school
can build internally and externally, the more it will increase its social
responsiveness.
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IMPROVING BY
ASSESSING
In the future, the high interdependency of organizations, institutions, and individuals in any modern society; the mounting quest to use moral and professional references in management practices; and the wide availability of information about any institution's performance will spare no medical school from being fully transparent regarding its contribution to people's well-being. Therefore, medical schools should subject themselves to introspection. They should take the initiative to set standards of social accountability and propose methods to assess and improve it. If they fail to be proactive, external forces may pressure them to act. Social accountability should be seen as a moral obligation as binding as the Hippocratic Oath for the medical profession and therefore fully recognized in the medical school's mandate. But more important, social accountability should be seen as an opportunity to broaden the scope of professional expertise and influence on the health scene. National accreditation systems for medical schools, where they exist, should incorporate a social accountability component.
Examining the functions and structure of the medical school is the main concern of known accreditation systems, and little questioning is done of the relevance of the products (graduates, research results, services) and their impacts on health care and health status. For instance, indicators of the quality of medical education tend to focus on areas such as the principles taught, the nature of teaching and learning methods, the availability and quality of staff and equipment, and the quality of libraries. Left almost untouched are areas such as career choices of graduates as compared with society's needs, work performance of graduates, and contribution of medical schools to continuing education programs.
Introducing the social accountability component to the accreditation of medical schools will push the scrutiny beyond the process of carrying out sets of actions to questioning the impact of these actions on health care delivery and possibly on the health status of the people the medical schools are to serve. In doing so, the accreditation process may help point out what actions medical schools should undertake and how best they can be implemented. Too few countries have formal accreditation systems, and only a small proportion even use irregular evaluation or inspection. As the desire for proper accreditation may quickly gain momentum worldwide, it is urgent to examine how accreditation mechanisms with social accountability components can be designed and adapted to various contexts
The debate about the appropriateness of using international standards to assess medical schools is not new. But globalization and the rapid exchange of ideas, information, and experts, as well as the emergence of international and continental trade agreements, renew and strengthen this debate.
First, we should distinguish the goal of establishing standards of universal value from the establishment of international standards. 'There is no point in advocating a uniform worldwide medical school model that disregards the specific features of the local cultural, epidemiologic, and socioeconomic contexts. A global consensus is desirable and possible, however, on the essential features of a medical school, on essential functions of physicians to be trained, and on essential principles and methods that any medical school should promote and apply in education, research, and service activities. Also, minimal sets of standards derived from these essential elements, as well as mechanisms for assessing to what extent these standards are met, should be recognized as being of universal value. In contrast, the term "international standards" may give the false impression that a supranational body is awarding a label of quality regardless of national specificities and requirements and should therefore be used with caution.
Regarding the assessment of social accountability, some basic elements would qualify for inclusion in a universal package. An example of such a package is given in Table 3. It consists of a series of steps that would apply to any medical school. However, the specific content of each step is to be described either by the medical school itself or by a national body responsible for regulating the quality of academic institutions and ensuring relevance to the local context.
The above "universal package" could apply
to any other academic institution in the health care sector and to any
health care setting. Collaborative research and development should be enhanced,
including at the international level, to elaborate on each step, develop
procedural guidelines to implement each step, and design and validate measurement
instruments, all to enrich a universal package for assessing social accountability,
so various stakeholders in the health care system may confidently respond
better to society's needs.
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CONCLUDING COMMENTS
Although social accountability must be assessed and promoted throughout the health care system, it is likely that if academic institutions-and medical schools in particular- developed a genuine interest in applying the concept, a ripple effect would be generated that would help influence future generations of doctors and other health care providers to serve society in the best interests of all.
Table 3
Reference points must be consistent with health goals. against which the performance of the institution will be assessed. Values of quality. equity, relevance. and cost-effectiveness in health care or equivalents should be retained as reference points. 2.Consider domains of education, research and service Social accountability is to be judged in each domain and consistency is to be sought among the three domains. 3. Develop basic sets of indicators Evidence must be provided on the level of attainment of social accountability in education: research, and service for each of the reference points. 4. Emphasize impact Privileged attention should be paid to the impact of health care delivery and health status resulting from socially accountable education, research, and service. To the extent possible. indicators and criteria must be developed for an objective appraisal. 5. Create meaningful partnerships When and as required. cooperative links must be established between medical schools, health services, health professions, and communities to create synergies and improve effectiveness of action on priority health concerns. 6. Accept external evaluation Internal evaluation must be followed by external evaluation involving, in addition to peers, representatives of health services. Health professions, and the society at large. 7. Use evaluation for institutional development The assessment of social accountability should be part of the overall evaluation of the medical school and used for accreditation. Results should be used to introduce sustainable institutional changes. |
Reproduced with permission from
Academic Medicine (Acad. Med. 1999; 74, August Supplement: S11-S20), the
journal of the Association of American Medical Colleges.
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