Education for Health

: 2012  |  Volume : 25  |  Issue : 3  |  Page : 180--194

The Social Accountability of Medical Schools and its Indicators

Charles Boelen1, Shafik Dharamsi2, Trevor Gibbs3,  
1 Independent Consultant in Health System and Personnel, Former WHO Program Coordinator, France
2 Faculty of Medicine at the University of British Columbia and Co-Lead Faculty of the Social Accountability and Community Engagement Initiative, Canada
3 Development Officer, Association for Medical Education in Europe, Independent Consultant in Medical Education and Primary Care, United Kingdom

Correspondence Address:
Charles Boelen
585, route d«SQ»Excenevex, 74140 Sciez-sur-Léman


Context : There is growing interest worldwide in social accountability for medical and other health professional schools. Attempts have been made to apply the concept primarily to educational reform initiatives with limited concern towards transforming an entire institution to commit and assess its education, research and service delivery missions to better meet priority health needs in society for an efficient, equitable an sustainable health system. Methods : In this paper, we clarify the concept of social accountability in relation to responsibility and responsiveness by providing practical examples of its application; and we expand on a previously described conceptual model of social accountability (the CPU model), by further delineating the parameters composing the model and providing examples on how to translate them into meaningful indicators. Discussion : The clarification of concepts of social responsibility, responsiveness and accountability and the examples provided in designing indicators may help medical schools and other health professional schools in crafting their own benchmarks to assess progress towards social accountability within the context of their particular environment.

How to cite this article:
Boelen C, Dharamsi S, Gibbs T. The Social Accountability of Medical Schools and its Indicators.Educ Health 2012;25:180-194

How to cite this URL:
Boelen C, Dharamsi S, Gibbs T. The Social Accountability of Medical Schools and its Indicators. Educ Health [serial online] 2012 [cited 2020 Apr 4 ];25:180-194
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Several parallel initiatives are underway around the world toward establishing standards to guide the development of socially accountable medical schools. However, the term social accountability is often used interchangeably with social responsibility and social responsiveness in reference to a medical school's social obligation.

The purpose of this paper is two-fold: first, to bring greater clarity to the concept of social accountability in relation to responsibility and responsiveness by providing practical examples of its application; and second, to encourage and facilitate a coordinated design of standards related to social accountability by expanding on a previously described model of social accountability, known as the CPU model, [1] and further delineating the parameters composing the model through examples, for translating them into meaningful indicators.

By clarifying the concepts of social responsibility, responsiveness and accountability and providing practical examples of their application, the indicators by which social accountability is understood, achieved and assessed will help medical schools and other health professional schools attain a higher level of confidence in developing and becoming a socially accountable institution.

 Clarifying Concepts

The terms responsibility, responsiveness and accountability often appear in reference to a medical school's social obligation. They are frequently used interchangeably yet they convey very specific meanings and applications. To reduce ambiguity, we provide below a definition of each term as used in this article, drawing from key citations in the literature.

In [Table 1] below we introduce what we have termed the "social obligation scale", as a way to consider the gradients of a medical school's social obligation in relation to the specificities within the concepts of social responsibility, social responsiveness and social accountability. These are then positioned against six elements, social accountability being regarded as the utmost and most desirable level of social obligation.{Table 1}

Using the educational mission as an example, the distinction between responsibility, responsiveness and accountability can be made as follows:

A socially responsible medical school is one that is committed to what faculty intuitively considers as the welfare of society. [2] The intention to produce "good practitioners" is based on an implicit identification of society's health needs. A socially responsive medical school is one that responds to society's welfare by directing its education, research and service activities towards explicitly identified health priorities in society. In this case, the faculty intends to produce graduates possessing specific competencies to address peoples' health concerns, such as the ones covered under the notion of "professionalism". [3] The socially accountable medical school goes one step beyond as it is not only taking specific actions through its education, research and service activities to meet the priority health needs of society, but also working collaboratively twith governments, health service organizations, and the public to positively impact people's health and being able to demonstrate this by providing evidence that its work is relevant, of high quality, equitable, cost-effective. [4] As far as the quality of its graduates is concerned, its aim is to produce change agents with capacity to work as well on health determinants and contribute to adapting the health system.

Distinction between these concepts can also be illustrated by the way an educational program on health equity is organized. For instance, a socially responsible school would include in its curriculum courses related to reasons for health disparity, while a socially responsive school would engage students longitudinally in community-based activities throughout their curriculum, assessing their competencies to care for the most vulnerable people and encouraging graduates to settle and work in underserved areas. A socially accountable school would take it a step further by negotiating with health authorities, strategies to ensure that working conditions are attractive for graduates to serve in such areas and participate in improved management of health services.

Similar gradients of social obligation could be applied to research and health service delivery missions. Hence, the social obligation scale positions social accountability as an explicit endeavor with assessable relationships between health needs' identification, engagements, inputs, processes, outcomes and impact on health in accordance with values of quality, equity, relevance and effectiveness. [5] It is also inseparable from an explicit commitment to work with other health actors in serving those values.

In summary, being socially accountable means working in partnership with key stakeholders such as policy-makers, healthcare organizations, health-insurance providers, health professionals, and civil society to make the greatest impact on people's wellbeing .[6],[7],[8] It is an explicit and palpable commitment towards identifying current and future health needs and challenges in society, to train future health professionals, develop a research agenda and propose health service models to respond to them as efficiently and effectively as possible, and to verify that there is an impact on people's health status. [9],[10],[11],[12],[13],[14],[15]

 Developing Assessment Standards

The shift from responsibility and responsiveness to accountability also entails that the emphasis on assessment must move from a process-oriented, internally assessed one (responsibility), to a more outcome-based one with assessment performed by an external evaluation team of peers (responsiveness), and finally to a focus on the impact of the school's products (i.e., graduates, clinical and research programs, and service models)on meeting people's health needs, with health partners being part of the assessors. However, two constraints continue to plague the efforts towards developing appropriate assessment standards: a technical one-establishing an instrumental relationship between a medical school's innovative work and improved performance of the healthcare system and improved health status; and a cultural one-related to the imperative need to work in close partnership with other health actors in serving the values of quality, equity, relevance and effectiveness.

Attempts towards setting standards date back three decades. In a World Health Organization (WHO) report in 1986, concern was expressed to alter the accreditation criteria of medical schools to better reflect people's priority health needs. [16] Subsequently, in the 1990s, WHO produced several reports and recommendations to revisit norms for quality assessment in medical education and medical school governance. [17],[18] In 1995, with the seminal WHO publication, "Defining and measuring the social accountability of medical schools", a grid was proposed to help design models of evaluation frameworks. [4] In 2009,in order to further clarify the statement set out by the WHO, Boelen and Woollard developed the CPU model, an acronym for "Conceptualization, Production and Usability", which provided a framework with key parameters in order to delineate the scope of commitments for a school to be recognized as socially accountable. [1] In recent years, a momentum has grown in support of social accountability of medical schools; this peaked in 2010, a century following the Flexner report, with the arrival of the document: Global Consensus on Social Accountability of Medical Schools. [19] Health professional educators, researchers, and policy-makers from around the world convened over the course of several months, and through using a Delphi technique, developed a set of strategic directions and key features, defining socially accountable medical schools. Translating the recommendations into validated standards is still ongoing; a noteworthy sample of medical schools under the aegis of an organization called THE net has subsequently designed an evaluation framework, inspired by the CPU model, and is engaged to conduct research to assess its validity to improve outcome and impact on health. [20]

The World Federation of Medical Education has also modified its medical education standards and has introduced new ones relative to principles of social accountability. [21] A similar review is being conducted by the International Organization of Deans of French-speaking Medical Schools, [22] and the Association of Medical Education in Europe, through its ASPIRE initiative (for International Recognition of Excellence), is at the point of testing a list of standards consistent with the CPU model and recommendations of the Global Consensus. [19],[23] Analogous plans are underway in a number of countries and regions around the world.

In view of the several parallel initiatives for drafting standards, all claiming compliance to social accountability principles, there is a risk of confusion and distortion. Consultation and synergy are required to increase credibility of the social accountability paradigm. In the following section, we elaborate on the CPU model in efforts to encourage a coordinated approach to the development of standards related to social accountability.

 Revisiting the CPU model

The CPU model provides a comprehensive list of parameters for evaluation and quality improvement for social accountability. It is system-minded as it attempts to cover a coherent sequence of steps encompassing intentions, deeds and consequences. It is composed of parameters exploring a wide range of elements from identification of current and future health needs and challenges in society and strategies to respond to them as efficiently as possible, to verification that interventions have produced the anticipated effects on people's health and wellbeing.

In summary, the CPU model is composed of 3 domains, 11 sections and 31 parameters (see [Table 2] and Appendix [SUPPORTING:1]). Domain C stands for "conceptualization" referring to justifications of actions against society's needs and challenges, domain P stands for "production" as it relates to processes and outcomes of action programs to meet those needs and challenges, and domain U for "usability" as it relates to deployment of "products" and their impact on health. {Table 2}

Reproduced from: Boelen C, Woollard R. Social accountability and accreditation: A new frontier for educational institutions. Medical Education 2009;43:887-94.

For a meaningful crafting of standards and indicators derived from the CPU model, it is important to further delineate the different domains, sections and parameters. The "Conceptualization" domain explores a medical school's capacity to formulate explicitly the current and anticipated needs of society and its ability to respond. This domain includes the following sections: References, Engagements and Governance. " References" are the raison-d'κtre of the institution, identifying mission, vision and values and the fundamental principles against which its excellence will be assessed. This will include how priority health needs will be identified, how challenges in the health system will be addressed, and how corresponding health workforce needs will be established. " Engagements" are motivated by the explicitly stated mission of the institution, and efforts to test and assess efficacy and effectiveness through field demonstrations carried out in partnership with other health actors. " Governance" relates to efforts towards best managerial practices to efficiently meet engagements.

The " Production" domain explores the capacity to conduct educational, research and service activities consistent with identified needs and challenges. This domain includes the following sections: Field operations, Educational program, Students, Teachers, Research and Service. The " Field operations" section designates the general context in which education, research and service delivery activities will take place in the field, with particular reference to first level of care, all consistent with previously taken engagements. " Educational program" covers the several features of good learning practices. The " Students" section refers to student recruitment but also anticipates their future careers, with emphasis on acquisition of a right mix of competencies. The " Teachers" section describes availability of teachers, their qualification and support. " Research" and " Service" sections refer to a balance of activities with a priority concern for those that can make a significant impact on health system management and people's health status.

The " Usability" domain explores the capacity to make the most fruitful use of the school's products as anticipated at the conceptualization stage; it includes sections of " Employment" and "Impact". In "Employment", the emphasis is on the future of the school's "products", be it graduates, research results or service models, implying school follow-up to ensure optimal use is made of them, eventually including participation in healthcare reforms to that effect. The "Impact" section describes the school's efforts to relate to other key stakeholders for achieving sustainable institutional change in the health system at local and national levels.

 Elaborating Measurement Tools from the Parameters

Users of the CPU model may wish to review systematically the meaning of each parameter in order to design measurement tools that are most appropriate to their context (see Appendix to this paper). Taken from the "References" section in [Table 2], two parameters-"values" and "population"-are presented below with corresponding indicators as examples.

 Values (Parameter 1.1)

Meaning. There is general agreement within the school and with the school's partners to refer to core values in designing a strategic plan and developing programs. Specifically, it is assumed that working towards the provision of the highest level of health for everyone in the nation is a generally agreed upon aim, health being defined as a complete state of physical, mental and social wellbeing, not just an absence of disease or handicap. Consistently, a school would comply with values such as quality, equity, relevance and effectiveness and align its plans and programs accordingly. Quality is the measure by which satisfactory responses are provided to meet a person's health concerns. Equity is the state whereby opportunities for health gains are available for everyone. Relevance is the degree to which most important and locally relevant problems are tackled first and most vulnerable people receive priority attention. Effectiveness ensures that greatest impact on people's health is sought, making an optimal use of available resources.

Examples of indicators

The school makes an explicit declaration to serve values of quality, equity, relevance and effectiveness by indicating it on school websites, brochures, and through other appropriate means. Equity in health is a lead reference for the school. Justifications and illustrations are provided resulting from an analysis of people's priority health needs.

 Population (Parameter 1.2)

Meaning. A situational analysis of the population is well documented from demographic, social, economic, cultural, environmental points of view, and taken into account within the school's missions and programs. Facts are obtained from reliable sources and/or directly sought through systematic surveillance or surveys. Main health determinants and risks to health are identified. Current needs are known and future ones are anticipated analyzing the likely evolution of society, via ongoing consultation within the academic circle and partners from outside.

Examples of indicators

A database is updated regarding a targeted population the school is willing to share healthcare responsibility for with other stakeholdersThere is a permanent consultative mechanism to enable the school to be aware of those people requiring special attention (i.e., homeless, pregnant women, isolated elderly) and on the collaborative work undertaken to serve them.There is a map of the country and local community featuring vital data hanging on walls of executive offices in the school.

The Appendix to this paper provides a complete list of parameters and corresponding indicators . Our expansion of the CPU model is meant to stimulate those engaged in the development, experimentation, validation and dissemination of appropriate assessment tools to provide evidence of progress towards social accountability of health profession educational institutions in their specific context of life.


In essence, the concept of social accountability is a system-based one, since it spans a series of interwoven events from identification of society's health needs and challenges to verification that planned interventions will and do have anticipated effects on health. Applied to medical schools, the concept recognizes its potential recognizes its potential for transforming society by acting, through educational, research and healthcare delivery programs, on a variety of health determinants and for helping to create an efficient and equitable health system. Likewise, the building of the evidence of a socially accountable medical school should follow a system approach. While current evaluation standards essentially focus on processes, social accountability widens their scope to include events occurring upstream and downstream these processes. Advancement of social accountability of institutions will in part depend on the capacity to design and test meaningful instruments for keeping stock and measuring progress. However, the availability of instruments should not be a substitute to the cultivation of the ethos to serve humanity in a spirit of social justice and best use of resources. The CPU model is an attempt to do so.

It is fair to say that social accountability is an ideal and that proposed indicators in the Appendix of this paper as well as others that may be crafted by medical schools are ways to assess progress towards this ideal. There is no universal set of indicators that may fit all medical schools in all situations in the world. The recognition of excellence in social accountability should be gauged in a given context at a given time for best use being made of available opportunities and resources for health development, also recognizing the fact that some of which are not under the control of medical schools. However, it is also fair to state that social accountability implies making extra efforts to create opportunities and find resources that can change the course of events in society and health systems and improve people's health status, well beyond the traditional remits of an academic institution, therefore requiring vision, courage and innovation to overcome conservatisms.

The pioneering work of an increasing number of medical schools and other educational institutions in the health sector to comply with principles of social accountability should inspire other stakeholders and incite public authorities to recognize it as a high mark of excellence.


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