|ORIGINAL RESEARCH ARTICLE
|Year : 2014 | Volume
| Issue : 2 | Page : 116-126
The training for health equity network evaluation framework: A pilot study at five health professional schools
Simone J Ross1, Robyn Preston2, Iris C Lindemann3, Marie C Matte4, Rex Samson5, Filedito D Tandinco6, Sarah L Larkins2, Bjorg Palsdottir7, Andre-Jacques Neusy7
1 School of Medicine and Dentistry, Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Australia; Training for Health Equity Network, Belgium
2 School of Medicine and Dentistry, Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Australia
3 Flinders University School of Medicine, Australia
4 Division of Medical Education, Dalhousie University, Canada (Formerly of Northern Ontario School of Medicine, Canada)
5 Ateneo de Zamboanga School of Medicine, Philippines
6 University of the Philippines Manila - School of Health Sciences, Philippines
7 Training for Health Equity Network, Belgium
|Date of Web Publication||31-Oct-2014|
Simone J Ross
MDR, Lecturer, School of Medicine and Dentistry, James Cook University, Townsville QLD 4811, Australia
Source of Support: The work reported in this paper was funded by Atlantic Charities Trust and the support of the Arcadia Foundation received through the Build Project 501(c3.)., Conflict of Interest: None
Background: The Training for Health Equity Network (THEnet), a group of diverse health professional schools aspiring toward social accountability, developed and pilot tested a comprehensive evaluation framework to assess progress toward socially accountable health professions education. The evaluation framework provides criteria for schools to assess their level of social accountability within their organization and planning; education, research and service delivery; and the direct and indirect impacts of the school and its graduates, on the community and health system. This paper describes the pilot implementation of testing the evaluation framework across five THEnet schools, and examines whether the evaluation framework was practical and feasible across contexts for the purposes of critical reflection and continuous improvement in terms of progress towards social accountability. Methods: In this pilot study, schools utilized the evaluation framework using a mixed method approach of data collection comprising of workshops, qualitative interviews and focus group discussions, document review and collation and analysis of existing quantitative data. Results: The evaluation framework allowed each school to contextually gather evidence on how it was meeting the aspirational goals of social accountability across a range of school activities, and to identify strengths and areas for improvement and development. Discussion: The evaluation framework pilot study demonstrated how social accountability can be assessed through a critically reflective and comprehensive process. As social accountability focuses on the relationship between health professions schools and health system and health population outcomes, each school was able to demonstrate to students, health professionals, governments, accrediting bodies, communities and other stakeholders how current and future health care needs of populations are addressed in terms of education, research, and service learning.
Keywords: Accreditation of medical schools, evaluation framework, health equity, health services research, health policy, social accountability
|How to cite this article:|
Ross SJ, Preston R, Lindemann IC, Matte MC, Samson R, Tandinco FD, Larkins SL, Palsdottir B, Neusy AJ. The training for health equity network evaluation framework: A pilot study at five health professional schools. Educ Health 2014;27:116-26
|How to cite this URL:|
Ross SJ, Preston R, Lindemann IC, Matte MC, Samson R, Tandinco FD, Larkins SL, Palsdottir B, Neusy AJ. The training for health equity network evaluation framework: A pilot study at five health professional schools. Educ Health [serial online] 2014 [cited 2019 Nov 18];27:116-26. Available from: http://www.educationforhealth.net/text.asp?2014/27/2/116/143727
| Background|| |
Calls for Medical Education Reform
A series of publications in the past 10 years have highlighted the importance of reforming health systems and addressing the shortage and maldistribution of health workers to reduce health inequities within and between countries. ,,, Health professional education institutions produce the key health system components of human resources/workforce and information/research and therefore have a central role in the complex process of reducing health inequities. The changing global landscape of health and health services has prompted a multitude of national and international groups and bodies to call for reforms in the education of health professionals to meet the changing needs of the 21 st Century, ,,,,,, including a greater emphasis on social accountability in the accreditation of medical schools. ,
In 1995, the World Health Organization (WHO) defined social accountability as:
"the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public." 
There is limited robust evidence on the effectiveness of any medical education reform, including social accountability efforts.  To provide this evidence, evaluation tools are required to explore how socially accountable medical or health professional education programs are actualized in different contexts and to inform evidence-based health and education policies.
In 2008 the Training for Health Equity Network (THEnet), a newly established consortium of health professions schools striving toward social accountability, recognized the need to collaborate to systematically build a common evidence and knowledge base on social accountability in health professions education schools. 
The THEnet grew out of a project initiated by the Global Health Education Consortium in 2007-8, which identified innovative schools of medicine and health sciences already addressing the health and social needs of underserved and marginalized populations.  All partner schools [Table 1] located in high, middle and low income countries have an explicit social accountability mandate to train health professionals for service in underserved areas in order to address workforce shortages in rural, isolated and poor urban communities. 
Despite contextual variation and settings, all schools aspire to several core educational and social principles [Table 2]. The schools all recruit students from communities with the greatest health care needs and employ preceptors or tutors from the community. Learning occurs in areas of greatest health care need, particularly in community-based settings. Significantly, all schools have a shared understanding of social accountability.
|Table 2: Descriptions of core educational and social principles of THEnet socially accountable health professions schools|
Click here to view
At THEnet's first meeting in Havana, Cuba in 2008, it was agreed to amend the WHO's definition of social accountability by highlighting a focus on the underserved; defined as communities that have least opportunity to access health services and health professionals:
"… The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public (and especially the underserved)."
In response to the need for more practical validated measurement tools, THEnet's first project was to develop an evaluation framework for schools to assess their progress toward social accountability and thereby their ability to influence health outcomes and health services. Collaboratively, over a period of 2 years (2009-2010), six of our foundation Schools - Ateneo de Zamboanga University, School of Medicine in the Philippines (ADZU); Flinders University, School of Medicine in Australia (FLINDERS); James Cook University, School of Medicine in Australia, (JCU); Northern Ontario, School of Medicine in Canada (NOSM); University of Philippines in Manila, School of Health Sciences at Leyte, (UPM-SHS); and Walter Sisulu University, Faculty of Health Sciences in South Africa (WSU) - jointly developed the THEnet's Evaluation Framework for Socially Accountable Health Professional Education Version 1.0. (EF). Originally produced in 2011 and later published in Medical Teacher, Larkins et al. describes the collaborative development of the evaluation framework. 
This paper describes the pilot implementation and findings of testing the evaluation framework across five THEnet schools. The pilot implementation sought to examine whether the evaluation framework was: (1) practical and feasible across contexts; (2) useful for schools for critical reflection on their performance and progress towards greater social Accountability; and (3) useful to assist schools establishing priority areas for research and improvement. The pilot test also sought to examine challenges to implementing the framework in different contexts.
THEnet's Evaluation Framework for Socially Accountable Health Professional Education
THEnet's Evaluation Framework for Socially Accountable Health Professional Education is a comprehensive set of processes, measures and tools that identify the key factors affecting a school's ability to positively influence health outcomes and health systems. THEnet used Boelen and Woollard's Social Accountability Conceptualization - Production - Usability model (CPU model) as a foundation for the evaluation framework.  The CPU model identifies three interdependent domains: (1) Conceptualization of desired professional - 'collaboration of the kind of professional needed and the system using his/her skills'; (2) Production of desired professional - 'components of training and learning' and (3) Usability of professional - 'initiatives taken to ensure graduates are put to their highest and best use" [15, page 890].
The aim was to develop a practical and useable framework, which could be used by non-expert evaluators and those whose primary language was not English. Technical concepts in the CPU model were adapted for a larger audience through use of simple English. Conceptualization, became Section One: 'How does our school work?'; Production became Section Two: 'What do we do?'; and Utilization became Section Three: 'What difference do we make?' 
Section One of the evaluation framework (How does our school work?) addresses important aspects of the organization and planning of the school frequently neglected in existing evaluation and accreditation frameworks.  These include an assessment of values, governance and decision-making processes and partnerships with the health sector, community groups and policy makers. This section also includes documentation and understanding of the reference population that the school serves, with particular focus on underserved groups within this. Identifying reference populations and health system, is a prerequisite for evaluating impact of particular strategies and programs. 
Section Two (What do we do?) centers on the three standard pillars of what medical/health professions schools do: education, research and service delivery. It looks at features such as the recruitment of students and educators, curriculum, learning methodologies, research, service, and resource allocation. This section aligns with the accreditation criteria for many health professions.  Uniquely, the evaluation framework emphasizes how these features link with priority health and health service needs of the schools' reference populations.
Section Three (What difference do we make?) focuses on the direct and indirect impacts that medical schools and their graduates have on the health of their reference populations and the health system they serve. It includes an assessment of a school's graduate outcomes (location, discipline and practice of graduates), its engagement and impact on health services and community health and social outcomes and influence on policy makers and other schools. 
It is important to note the evaluation framework is not designed as a summative pass or fail exercise, but rather as a process to guide and support schools to take a critical look at their performance, progress, knowledge, skills and capacity in socially accountable health professions education. In addition, the evaluation framework can assist schools to establish priority areas for improvements in education, service and research.
| Methods|| |
While THEnet schools share common principles, the schools that pilot tested the evaluation framework vary in enrolment numbers, training settings, curriculum approach and educational methodologies [Table 3].
The methodology had three phases: 1. A workshop; 2. Focus groups and interviews with collation and analysis of existing data; and 3. Individual school reports. Six of THEnet's foundation schools completed the workshop (JCU, FLINDERS, NOSM, WSU, ADZU, and UPM-SHS). Five schools piloted the evaluation framework over a 2-year period; FLINDERS, JCU and NOSM in 2010 and UPM-SHS and ADZU in 2011. UPM-SHS and ADZU piloted a revised version of the evaluation framework from the 2010 pilot. [Figure 1] outlines the methodology of the pilot study across schools.
|Figure 1: Process for development and pilot test of the evaluation framework|
Click here to view
Phase 1: Each pilot test began with a workshop with faculty, staff, students and community members to assess the evaluation framework as a critical reflection tool within the context of each school.
Phase 2: Progress against the aspirations in each section of the evaluation framework was assessed through interviews and/or focus groups with academic/faculty and professional staff members, students at different levels of the course, and community members and health sector representatives.
An implementation guide was created to standardize the processes of administering the framework across schools. It was agreed early that each school was to conduct focus groups and interviews with students, faculty and staff, and community members to receive a full range of perspectives of social accountability across the school. The number of focus groups and interviews and exactly who participated was left up to each school to define within their own context and educational system. All schools had the agreement to purposefully choose participants who would be open with critical reflection, and/or with corporate knowledge of the school. Participation was voluntary and steps were taken at each school to assure participant confidentiality and anonymity.
The range of focus groups and interviews conducted depended on the context of each school. For example, ADZU has a 4-year postgraduate course, and conducted seven semi-structured focus groups with students (five) and community representatives (two), and seven interviews with faculty/staff. In comparison, JCU has a 6-year undergraduate course, and conducted seven semi-structured focus groups with students (two), faculty/staff (three), community representatives (one) and volunteer patients (one).
In comparison, FLINDERS and UPM-SHS piloted the evaluation framework across a school that delivers a number of different health professions courses; therefore FLINDERS conducted 10 semi-structured focus groups with students (four), faculty (five) and stakeholders (one), and 21 interviews with stakeholders (2) and faculty/staff (nineteen). In comparison, UPM-SHS conducted eight semi-structured focus groups with medical students (two), nursing students (one), faculty (one), alumni working in rural settings (two), public health service providers in a learning community (one) and representatives from the schools reference community (one).
To assure consistency of data collection an interview guide was created. It was first piloted at NOSM, JCU and FLINDERS, and then at UPM-SHS and ADZU. This ensured all schools asked the same six key questions at each focus group or interview [Table 4].
Both ADZU and UPM-SHS schools translated the questions into local dialects and retranslated participants' input into English. The data at all schools was analyzed using a qualitative 'grounded theory' approach, developing theories and theoretical propositions from the data.  JCU and FLINDERS also coded electronically, JCU coded using Microsoft Excel and FLINDERS using NVivo. No information that might identify individuals was recorded at any school.
Progress toward the aspirations was further analyzed through collation of existing sources of evidence as suggested in the evaluation framework. A full description of the development, and the evaluation framework can be found in Larkins et al. 
Phase 3: Each school reported on the results of their own pilot study and the evaluation framework was refined and finalized in accordance with the findings. The report included: (1) feedback on the evaluation framework and its feasibility for implementation, (2) feedback on the pilot process and suggestions for adaptations to the process for broader implementation, and (3) key recommendations for improvement for each school in response to the results of the pilot implementation.
Findings from the five schools were collated and the results were discussed to confirm findings and to consider contextual variations between schools, which may have impacted on implementation.
Each school individually obtained ethics approval to conduct the pilot implementation.
| Results|| |
Each school found that the evaluation framework was applicable in their cultural and school contexts and that information could be collated for most of the key components. The evaluation framework was used in its entirety and as a 'whole of school' process, not at department or program levels. Full support from school leaders, including deans, was essential to both effectively conduct the pilot studies and implement the study's findings.
Each school agreed that the evaluation framework provides an opportunity to take a comprehensive and critical look at their performance and progress toward greater social accountability. The three sections of the evaluation framework identified the areas of strength, gaps and a list of priority areas for research that will guide each school to translate social accountability in practice and to develop and establish priority areas for research and program development. The key findings from the pilot evaluation framework implementation are summarized below and in [Table 5].
|Table 5: Summary table of findings from schools who conducted the evaluation framework pilot study|
Click here to view
Section One: How Does Our School Work?
This section produced similar findings across schools and posed a set of challenges. For example, at some schools, although focus group or interview participants could identify a reference population, there was limited formal documentation to support this understanding. Also, all schools include underserved communities in their reference population; however, the term "under-served" is highly dependent on the context and needs to be better defined by local stakeholders.
Although the types of partnerships and collaborations varied across schools, each could verify through meeting notes, focus group discussions and memoranda of understanding that government and non-government organizations, communities and community health centers, local and international institutions, and student groups are stakeholders involved in decision-making processes within the school.
All schools also identified that finding documentation in support of Section One was difficult, as some of the decision-making processes were not well documented, could not be located or were held only in the corporate memories of key school personnel. This was marked as a recommendation or gap in each school report. However, this result was also found to be a benefit to schools, as documents are now being written which allow clearer communication of social accountability activities to new faculty and staff joining the school.
Section Two: What Do We Do?
This section identified many similar findings across schools, despite each school having different strategies for meeting their own social accountability goals. Student support was contextualized to student educational needs, and students were well supported at all schools. All schools could cite examples of collaborative and community based research projects in all areas of health and wellbeing. However, only some schools had sustainable funding for research with underserved communities. Each school has students working in the community, which provides a positive effect on health service delivery.
Section 3: What Difference Do We Make?
While the aspirations in section three are largely overlooked in most accreditation measures and are frequently considered beyond the scope of health professional education institutions, these factors are crucial components when evaluating social accountability in health professions education. The three schools (JCU, ADZU, UPM-SHS) that were actively tracking graduates were able to demonstrate higher retention rates of graduates than traditional schools within priority areas, where health professionals are most needed. Different strategies were used to determine graduate impact beyond graduation. Many of the schools disseminated their social accountability research and community based practices in different forums including local, national, and international conferences. The UPM-SHS and ADZU schools both have had positive impact on partnering with other non-THEnet medical schools in their own country and elsewhere to develop their socially accountable medical program.
Nonetheless, schools found that fully completing Section 3 would require significantly more resources, tools and time than allocated to this project.
| Discussion|| |
To ensure evidence-based reform as advocated by the Lancet Commission,  health professional schools must be able to assess their effectiveness in addressing the needs of the communities and health systems in which they operate. This includes an evaluation and long-term impact study on where their graduates are working, in what type of practice they are engaged, and whether the competencies they obtained during their education adequately prepared them to serve their communities, including the underserved. The evaluation framework underscores these impacts and engages institutions in systems thinking that is necessary to understand and address the complex challenge of improving education to strengthen health system. It provides a comprehensive framework to gather and analyze information that can help align education and health systems planning. ,
Although operating in very different contexts in low and high resource countries, THEnet schools found the evaluation framework a practical and useful tool to assess their progress toward greater social accountability. While all of the schools have missions and activities already aligned with the core educational and social principles of social accountability, each school was able to identify areas for improvement and further research. The implementation of the evaluation framework provided an opportunity for schools to demonstrate their commitment to social accountability through critical self-reflection. It highlighted to each school the need for resources to further their work and also the importance of producing demonstrable outcomes or impact, for example, that graduates are serving in communities of need and contribute to improving health outcomes of the population they serve and to strengthening the local health system.
In terms of pilot implementation of the evaluation framework, differences between more financially resourced and less financially resourced schools were not prominent. The major differences in the results related to the diverse operational styles and context of the schools rather than any financial, cultural or social variations. This indicates that the evaluation framework is applicable across contexts and is flexible enough to cater for differing cultures and resource levels of schools.
Context-sensitive instruments such as the evaluation framework have the potential to increase our understanding of factors that hinder or facilitate health equity. Collectively, contextual differences between THEnet schools greatly assisted the evaluation framework development.
This pilot study has highlighted the need for more research as well as better tools and resources to assess the links between how academic institutions operate, their programs and activities, and ultimately how these factors impact their graduates, reference population and the health system in which they operate.
Recently there have been initiatives to develop tools that track graduate outcomes; most notably the Medical School Outcome Database in Australia and New Zealand.  THEnet is building on those efforts and that of individual member schools to develop graduate outcome tracking tools for the evaluation framework that can be used across contexts and will provide a larger cohort and allow cross-institutional comparison in a variety of contexts and continents increasing reliability and validity. It is also designing impact evaluation tools to further strengthen the resources available as part of the evaluation framework.
THEnet is evolving into a broader learning community and since the pilot study, five new schools have joined THEnet. At the time of writing this paper (January 2013) each of these schools is in various stages of implementing the evaluation framework, thus providing additional feedback. This feedback, as well as new tools and research findings will be integrated into version 2.0 of the evaluation framework. This additional work will improve the understanding of the links between the three sections in the evaluation framework and its core components and thereby strengthen the evaluation framework.
Ultimately, the evaluation framework will be used to gather data across schools and contexts with the aim of using the results for evidence-based policy guidance and continuous, transformational improvement and reform of health professions education at national, local, institutional and practice levels.
There were some limitations in this pilot study mostly due to limited financial and time resources. First, in all piloting schools, faculty conducted data collection, focus group discussions, interviews and reporting; there were no external evaluators. We feel this is not problematic for this pilot study, as it was conducted to look at the feasibility and practicality of the evaluation framework; however, internal rather than external researchers presented opportunity for bias. Nonetheless internal evaluators offered strength in terms of relevant understanding, and all researchers were experienced in qualitative methods and used reflexivity and researcher triangulation to minimize potential conflict.
Second, the schools that created the evaluation framework also evaluated its feasibility in the pilot study. One recommendation of the pilot is to further develop the evaluation framework to be used as both a critically reflective tool and a peer review tool, with peer review teams to address any potential bias.
Third, faculty who not only designed the evaluation framework but who held an important position at the school conducted focus groups and interviews. This was identified as a potential conflict early and the two Australian schools (JCU and FLINDERS) organized non-THEnet member facilitators for the interactions with participants.
Last, there were translation problems from English to Filipino for the two Philippine schools (UPM-SHS and ADZU), as the Filipino language does not have a term for 'Social Accountability'. While the evaluation framework has been translated into Spanish and French; common terms and understandings for social accountability need to be developed in languages other than English to add real meaning.
| Conclusions|| |
This relatively small but diverse pilot study has demonstrated that the evaluation framework is a practical and useful tool, and whole of school reflective process for health professional schools to assess their progress toward social accountability. The evaluation framework is a feedback mechanism for a school, to improve its programs and activities in terms of relevance, equity, and quality and to further develop the school's partnership with the health system.
This pilot study has informed THEnet's research activities, which will ultimately contribute to strengthening the evaluation framework. Additional research and tools are needed to improve the evaluation framework as well as further testing at schools engaged or interested in reforming health professions education. It is an evolving tool that will continue to develop by our group as more schools within and beyond THEnet provide feedback. These new tools and the evidence gathered using the evaluation framework will enable schools in different cultural and social settings to demonstrate to students, health professionals, governments, funders and communities that they are addressing the current and future health care needs of their local populations.
The evaluation framework is available from THEnet website (www.thenetcommunity.org) in English, French and Spanish, or can be electronically provided through email consultation at firstname.lastname@example.org. An interactive on-line version will be available at the above website from mid-2014.
| Acknowledgments|| |
The authors also wish to acknowledge other contributors to the evaluation framework: Charles Boelen, Kate Brennan, Juan Carrizo, Pasqualito Concepcion, Fortunato L. Cristobal, Aaron Goldstein, Jennene Greenhill, Dan Hunt, Jehu Iputo, Afdal Kunting, Joel Lanphear, David Marsh, Khaya Mfenyana, Jose Alvin P Mojica, Ileana del Rosario Morales Suárez, Richard Murray, David Prideaux, Jusie Lydia Siega-Sur, Roger Strasser, Paul Worley, Sarah Strasser, and Zorayda Leopando.
Please note: This paper discusses University of the Philippines Manila - School of Health Sciences at the time of evaluation (2011-2012), but with deep respect for the devastating effects of Typhoon Haiyan that struck Leyte in early November 2013, this paper is dedicated to the faculty and students of UPM-SHS. THEnet and partner schools are committed to working with UPM-SHS in their rebuilding efforts. For more information see: www.thenetcommunity.org
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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