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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