What we Measure

The ISAT is divided into Core Components focusing on the assessment of key elements. While each of these Core Components are relevant to most medical schools, not all of them can be assessed in the same way, given that the context (including policies and regulations) can vary from country to country and institution to institution. Each section below explains why the component is deemed important for the pursuit of social accountability, with the understanding that it may not be applicable for all.

Most nations in the world struggle with recruiting and retaining health professionals in rural, remote, and underserved regions. The reason that this is a Core Component for social accountability is that evidence shows that who gets admitted into medical school matters. However, it should be noted that in some countries, schools have no influence on who attends their program because selection is done at national levels (for example, in Argentina there are no specific criteria for entrance into medical school once students graduate from secondary education). In such cases, schools striving towards greater social accountability can advocate for policy changes, reach out to underrepresented groups, and provide special academic, financial, and psychological supports to students from rural or underrepresented groups.

Currently, in most regions of the world, student selection criteria are predominantly based on students’ academic performance. However, studies have shown that a combination of several factors are good predictors to increase students’ motivation to practice in rural areas and underserved communities (for example, having a rural background). Schools striving towards social accountability have employed several strategies to increase the socioeconomic, ethnic, and geographical diversity of students and to select students who they deem most likely to choose careers and practice locations in areas of need. These strategies include quota systems providing additional weighting for students from rural or underrepresented populations; community involvement; school marketing strategies; and selection-based psychometric tests to assess personal attributes such as strong interpersonal skills and empathy (24).

Where admission or student selection committees are in place, socially accountable schools include key community members of underserved or marginalized populations as decision-makers on their committees. For example, the relevant Canadian accreditation standard calls for medical schools to “address the priority health concerns of the populations it has a responsibility to serve. The medical school’s social accountability is: a) articulated in its mission statement; b) fulfilled in its educational program through admissions, curricular content, and types and locations of educational experiences; c) evidenced by specific outcome measures.”

Recruiting and retaining a cadre of dedicated and well trained academic and clinical teachers is challenging in many countries, particularly in rural and underserved areas. In some high-income countries such as the United States, medical school institutional value systems tend to prioritize research over teaching. Moreover, in poorer regions of the world academic position are often not well paid and faculty often earn additional income by other means which reduces the time they dedicate to teaching and mentoring students. Socially accountable schools seek to attract faculty who: have the competencies needed to address the health and health system needs of the region where the school is located, and who come from diverse socioeconomic and cultural backgrounds (and if possible, from the community they will serve). Schools also aim to recruit an appropriate balance of biomedical, population, clinical, and social sciences faculty, while aiming for gender parity. Rural schools are at a disadvantage compared to urban or peri-urban schools in their ability to recruit qualified faculty. However, community engaged medical education, a hallmark of social accountability, is generating additional new needs but also opportunities for schools to recruit faculty with strong interprofessional skills, able to work across disciplines and sectors in areas of shortage. In addition, socially accountable schools also recruit, train, and support practitioners and other health care providers practicing in the community as adjunct faculty/educators in clinical and social sciences, thus expanding its pool of community preceptors. Rural schools offer unique opportunities for faculty committed to social changes and interested in making a tangible difference in the health and well-being of underserved rural communities. These schools are also providing the opportunity to contribute to the evolving transformation of medical education needed to produce a fit for purpose health workforce.

The world of medicine and health is rapidly changing with implications for medical education and practice. These changes include demographics, epidemiological transition, environmental challenges, emphasis on clinical quality and patient safety, financial challenges, and rapid advances in information technology, big data, and artificial intelligence. While these changes vary within and between countries, faculty often receive limited training related to educational principles and teaching methodologies, student assessments, and on content related to local priority needs in the communities the school serves, including public health, communication, and topics relevant to the social determinants of health.

To increase the number and quality of the teaching faculty and improve their skills in education and research some schools establish a Faculty Development program either as part of an education department or as a separate program. Such department develop programs that support continuous professional education using information technology and other communication tools. The faculty development program can draw on the various resources from the other schools at their university such as social and political sciences, engineering, other schools of health sciences and community-based organizations to shape a comprehensive curriculum on social determinants health and community development to prepare medical students for their community placements and to support the community engaged service-learning education program. Faculty members will be instructed in pedagogical principles of interprofessional education and active student-centered and service learning during student community placements. The program will provide teaching and pedagogical resources to community practitioners recruited as adjunct faculty to improve their attributes/skills to be effective mentors, teachers and preceptors.

The curriculum development occurs through a consultative process, drawing on resources of other schools worldwide and accreditation standards. In partnership with the community, community-based organizations and local health system the school identifies health and social priority needs of the communities they serve and integrates them in the scientific base of the curriculum content woven in to the basic, population and clinical sciences and social sciences to include comprehensively all these aspects of medicine. This shift a predominant narrow bio-medical model towards a socio-biomedical curriculum designed to advance the teaching mission of the school, building on the strength of the community confronted with continuous evolving needs. The curriculum includes a longitudinal theme on the social determinants of health woven through the various courses of the curriculum. The school education department acts as an educational resource hub for faculty and students and provides support and tools for curriculum development, teaching methodology, assessment of educational programs student and faculty assessment (formative and summative), simulation program and standardized patients and track students’ progression throughout their cursus.  The curriculum develops interdisciplinary courses by enlisting faculty from other schools who may receive dual appointments.

To increase social accountability, addressing the needs of students is key. The learning methods in socially accountable programs are aligned with the school curriculum, often blended, and focus on learners and the best available methods to ensure they attain the desired competencies. Over the past decades learning methods changed from being an apprenticeship model that was teacher and subject centered where students had little input towards a competency-based, student-centered and more interactive learning that provides students with competencies such as critical thinking, reflective practice, problem-solving and the skills to foster life-long learning. To address the need to train productive interdisciplinary teams able to work in any settings including in marginalized communities, an increasing number of schools use interprofessional and team-based learning, service-learning, experiential, self-driven as well as case and problem-based learning approaches. Advances in information technology (IT) have also increased schools’ ability to have students stay in rural or remote settings for extended periods while continuing to learn with their fellow students located elsewhere as well as receiving remote-mentoring. IT also provides opportunities to learn skills and knowledge through virtual reality applications, gaming and other technology supported approaches.

The conventional education model—still predominant across the world—is mostly delivered in classrooms with the clinical learning occurring primarily in hospital settings. Already in 1961 It was pointed out that training students mainly in university hospitals is illogical and inefficient (25). Patients who are admitted to the hospital are frequently pre-diagnosed before being admitted and their length of stay is getting shorter and shorter. Moreover, few medical schools provide their students with substantial exposure to outpatient or general practitioner facilities, where most diagnosis and management of chronic diseases takes place (26). The implications are that students have limited understanding and exposure to the different stages of disease progression and of the conditions that generated them including social determinants of health (SDH).  Socially accountable health workforce education seeks to provide a balanced mix of clinical experiences between primary care setting, secondary and tertiary hospitals and opportunities for students to better integrate learning about the social determinants of health into the curriculum. Most socially accountable schools provide some form of longitudinal integrated clerkships or extended times in community settings (27,28).  This community engaged education approach presents remarkable opportunity to learn to work in interprofessional teams and for joint strategy and mutual learning between academia, local health authorities, communities and community-based NGOs. With their mentors, community members and other local partners students often conduct community survey, identify priority issues and design and implement interventions based on agreement with all stakeholders and lastly the student evaluate the project results and impact. Community based rotations integrate theory and practice and offer unique opportunitities for close collaboration between the schools of medicine, public health, pharmacy, social sciences and other to work together with local community-based organizations and health centers to develop and integrate the SDH into the curriculum and develop a interdisciplinary team-based approaches within community health programs tailored to priority needs.

Social accountability calls for schools to align their research towards the priority needs of the communities they serve and to collaborate with communities in the design and implementation of research projects. The reciprocal partnership between the school, the communities it serves, and the health care system delivery provides unique opportunities for establishing a collaborative research agenda, conduct research on health equity and community health, and around how the school could better address health system and health priorities of their populations. It also provides opportunities for the school to do research on how the educational process and education outcomes aligns with the needs of the health system and the priority needs of the communities.  Socially accountable schools are currently generating evidence on the way the education and training program can influence the shortage and maldistribution of health practitioners, particularly in rural underserved regions. Community-based training brings the students in close contact with underserved communities where they build social and personal ties, live in the same conditions and experience the socio-cultural and professional environment where they are expected to practice. This provides faculty members and students a large arrays of research topics on causes and factors responsible for generating health inequities in the communities and to develop joint strategies and remedial interventions. Social accountability also calls for faculty and students to be attuned to ethical consideration related to community engaged research and assess the impact research findings are having on policies, practice and health in the communities the school serves. 

According to the AMEE Guide on Producing a socially accountable medical school as well as other key document on social accountability, incorporating social accountability principles into governance of an institution or program is an essential step. This includes social accountability principles and strategies being integrated into decision making, planning, evaluation, resource mobilization and allocation as well as day to day management (18, 29-31).  While many schools incorporate principles of social accountability — such as including altruism or service to people and communities — into their vision, mission and value statements, they are not socially accountable unless these aspirations are reflected in the content of the program and how the school is governed. This includes the existence and use of metrics and benchmarks to assess how well the school or program is meeting the needs of the communities, region and society it serves. Social accountability also calls for schools to include internal stakeholders such as students, staff and faculty as well as external stakeholders such as marginalized communities, service providers and local authorities in decision making. For socially accountable schools engaging with communities, it serves is hardwired into every aspect of their work, so community members are members of boards of directors or other governance and advisory bodies. A school’s governing body makes key decisions regarding strategies, policies and programs, including on how to allocate resources. However, it should be recognized that the school’s autonomy in making these decisions can be considerably restricted by policies from the university, provincial and/or central government.

Engaging and partnering with the stakeholders in health professional education and health is at the core of the definition of social accountability of medical schools: ”… the priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public”(2). The Innovation Collaborative on Learning through Community Engagement, a participant-driven group formed by members of the National Academies of Sciences, Engineering, and Medicine’s Global Forum on Innovation in Health Professional Education in the United States defines health professional education as community-engaged “…when community–academic partnerships are sustained, and they focus on the collaborative design, delivery, and evaluation of programs in order to improve the health of the people and communities the programs serve. Programs and partnerships in community-engaged education are characterized by mutual benefit and reciprocal learning, and they result in graduates who are passionate about and uniquely qualified to improve health equity” (30). According to the report of the High-Level Commission on Health Employment and Economic Growth suggest that curricula should be developed in partnership with communities served by the school and with other stakeholders. (4). These include students, service providers, community-based organizations, governments and members of underserved populations.

“The accountability of academic institutions usually ends at graduation or the publication of a paper. Outcomes—such as the placement, practices, and retention of medical graduates in areas of greatest need and the policy or practice impact of a research project—are seldom tracked.”

Since socially accountable programs and schools set out to produce graduates that choose careers and practice locations that are aligned with health system needs, including the needs of marginalized populations, it is essential that they track their graduates. Countries such as Australia who struggle with dearth of medical professionals in rural and remote regions and who have invested significantly in increasing recruitment and retention in those areas have set up national databases to track graduates. However, much of current tracking efforts are done by schools themselves or third parties such as program funders. Graduate tracking can also improve the education and training programs by learning what influenced graduates’ career and practice location choices. Schools use various means to remain in contact with graduates, conduct research to identify important factors that affect their choices and set up systems and processes to track students’ intentions and graduates from entry into health professional education until several years after graduates

To ensure that programs and schools are addressing evolving needs in the society, regions and communities they serve, schools need to regularly seek to evaluate the outcome of their efforts as well as the impact they are having on graduates and their practice. Ultimately, they should mesure their impact on policies, practice and performance of the health system and health in the communities they serve. Assessing the effect of education strategies on health systems and population health is clearly challenging as it is influenced by a multitude of complex, interlinked, dynamic factors and conditions many of which are not within the control of the education institution. Consequently, researchers need to apply multiple methodologies to build evidence for attribution, contribution, and accountability. (19) Schools striving towards greater accountability and impact are beginning to assess impact. Emerging evidence is presented the World Health Organization’s 2017 publication Health Employment and Economic Growth: An Evidence Base and other publications referenced (4,13,32).

There is a growing interest in broadening the scope of social accountability to include the concept of environmental accountability (33). The 2018 AMEE ASPIRE Social Accountability Criteria now include the obligation of medical schools to ensure they actively develop and promote environmentally sustainable solutions to address the health concerns of the community, region, and the nation they serve. While most of the social accountability literature focusses on medical student (MD) education, the impact of graduate medical education (vocational training) plays a vital role in the production, deployment and impact of the medical workforce. The role of medical schools in providing graduate medical education varies structurally around the world and is beyond the scope of the ISAT Tool which has been designed to focus on the role of the medical school.