Education for Health

INVITED PAPER
Year
: 2019  |  Volume : 32  |  Issue : 1  |  Page : 41--48

Accrediting excellence for a medical school's impact on population health


Charles Boelen1, Danielle Blouin2, Trevor Gibbs3, Robert Woollard4,  
1 International Consultant, Former Coordinator of the WHO (Geneva Headquarters) Program of Human Resources for Health, Kingston, Ontario, Canada
2 Faculty of Health Sciences (Department of Emergency Medicine) Faculty of Education Queen's University, Kingston, Ontario, Canada
3 President, Association for Medical Education in Europe (AMEE), UK
4 Co.Chair, Global Consensus for Social Accountability; Professor of Family Medicine, University of British Columbia, Vancouver, Canada

Correspondence Address:
Robert Woollard
Global Consensus for Social Accountability, Professor of Family Medicine, University of British Columbia, Vancouver
Canada




How to cite this article:
Boelen C, Blouin D, Gibbs T, Woollard R. Accrediting excellence for a medical school's impact on population health.Educ Health 2019;32:41-48


How to cite this URL:
Boelen C, Blouin D, Gibbs T, Woollard R. Accrediting excellence for a medical school's impact on population health. Educ Health [serial online] 2019 [cited 2019 Oct 21 ];32:41-48
Available from: http://www.educationforhealth.net/text.asp?2019/32/1/41/266182


Full Text



This paper has been reviewed and all ideas expressed are supported by a number of individuals well versed in the subject under study. They have accepted to be co-signatories. They have accepted to be co-signatories [Appendix].

 The Landscape



We take the stance that excellence is the capacity to make the highest possible contribution to human welfare. In terms of the health sector, the WHO initially defined health as “the complete state of well-being, physical, mental and social, not just the absence of disease or infirmity.“ In subsequent years, this has been elaborated such that health may be broadly defined as the ability of an organism, an individual, or a society to adapt positively to changes in their internal or external environment.[1] Such benefits must accrue to each segment and individual in a given society. Such an ambition can only be fulfilled by a convergence of multiple factors and synergistic actions of several health, social, economic and political actors. We believe that the better we can identify those factors and coordinate action among its actors, the higher the chance to excel.

Health systems worldwide face a number of common challenges in the delivery of efficient, cost-effective, equitable, and sustainable healthcare [Table 1]. These challenges cannot be ignored. There is mounting evidence that a comprehensive approach to health challenges is desirable and doable and that increased spending on medical care will not alone improve health status.[2],[3]{Table 1}

In this complex and rapidly evolving context, several questions remain unanswered [Table 2].{Table 2}

 Coordinating Medical Schools and Health Systems



The call for stronger relationships between health systems and medical education is not new. It was one of the key recommendations of the World Summit on Medical Education held in Edinburgh in 1988.[4] Thirty years later, the linkage is far from optimal.[5] Over the years, a number of national and international initiatives have promoted ways to foster synergy among key health bodies in an effort to close the gap between the education of physicians and relevant response to priority health needs. In 2010, the Lancet Commission [6] articulated the interaction and its importance, drawing a model for intersectoral partnership and action. More recently, two important reports emphasised the need for collaboration: The WHO Global Strategy on Human Resources for Health: Workforce 2030[7] and Working for Health and Growth: Investing in the Health Workforce from the High-Level Commission on Health Employment and Economic Growth.[8] The latter, jointly issued by the WHO, the ILO (International Labor Organization) and the OECD (Organization of Economic Co-operation and Development), under the aegis of the United Nations, calls for strong alliances across sectors to develop human resources in quality and quantity as an essential contribution to universal health coverage, and warns that “success… is often influenced by the strength of mechanisms to hold key actors accountable in the development and implementation process.”

The concept of social obligation for academic institutions must be clearly defined. In 1995, for the first time, the WHO defined the social accountability of medical schools as “the obligation to direct their education, research, and service activities toward addressing the priority health concerns of the community, the region, or nation they have a e mandate to serve. The priority health concerns are to be identified jointly by governments, healthcare organizations, health professionals and the public”.[9] In this seminal document, the WHO urges medical schools to be guided by the values of quality, relevance, equity, and cost-effectiveness in healthcare. In 2010, a Global Consensus gave a more precise definition to what a socially accountable medical school would look like.[10] In 2017, a World Summit on Social Accountability [11] undertook to animate this consensus through advancing accreditation, partnerships, leadership, and defining desired competencies for health professional graduates. This produced a consensus, the Tunis Declaration, defining mutual commitment to relevant action.

Since the concept of social obligation has been interpreted in very different ways over the years, a proposal was made in 2011 to consider the concept as a continuum of three gradients: social responsibility, social responsiveness, and social accountability.[12] In this proposal, social responsibility is defined as the “engagement to act at everyone's best capacity on what is implicitly understood as the health needs of people and society.” Social responsiveness requires a more explicit and quantifiable identification of priority health needs, to allow schools to use their resources in a more purposeful way and ensure that their graduates acquire competencies most relevant to the identified needs. The term social accountability is used to characterize the highest degree of social obligation. It requires that monitoring is undertaken to ensure that the desired outcomes and impacts are attained on graduates' performance, health service delivery, and population health status, in line with basic principles of quality, equity, relevance, and cost-effectiveness. This definition of social accountability was accepted by the Global Consensus for Social Accountability of Medical Schools resulting from an eight--month long Delphi process conducted among international experts and organizations engaged in medical education and academic governance.

 Academic Excellence and Medical Schools



Medical schools are a health stakeholder with strong potential to mobilise forces toward improved population health status. This is because of their unique combination of education, research and service delivery missions and their inherent academic ethos to base decisions on evidencefree from any ideology or partisan inclination.[13] Even if they are successful in preparing competent physicians, producing relevant research and participating in the delivery of first-class care services, medical schools are well aware that their contributions are only pieces on a complex health chessboard. Many other health determinants and stakeholders exist over which they have little or no direct control. Therefore, coordination of these various stakeholders is essential, even if it may be challenging.[14]

Schools committed to reducing health disparity through a fairer distribution of health workforce in their region cannot restrict their focus to selection processes, curriculum reform, trainee distribution, or intensive exposure of students to community needs as means to encourage graduates to settle in underserved areas. They must also partner with potential systems, in which their graduates will work and explore employment opportunities, ensure attractive working conditions, and support effective health-care models. After years of experience, such schools are able to demonstrate that these practices yield promising outcomes, evidenced by improvements on health indicators and economic growth, both in rich and emerging economy countries.[15],[16]

We may thus argue that the concept of excellence can be epitomised by a triple capacity:

The capacity to identify current and future health needs and challenges of citizens and society as a wholeThe capacity to adapt the schools' missions and programs to address those needs and challenges, andThe capacity to monitor the effects of relevant actions on identified needs and challengesFollowing this approach, and taking medical education as an example, medical schools would be confronted with the following questionsDo our graduates possess the relevant competencies to address society's priority health concerns?Have we effectively orientated their career choice toward issues and areas of greatest needs?Have we established solid relationships with our health systems to ensure that future working environment is conducive to practicing the competencies acquired during medical training?What contributions should we make to health system reforms?

A similar introspection should be expected for both the research and service delivery missions of schools.

Medical schools practising such an evaluative feedback approach would clearly demonstrate traits of academic excellence as they sought to provide evidence that their commitment to improve the quality, equity, and effectiveness of health services has impacted or is likely to impact their populations' health.

 Accreditation as Promoter of Excellence



To support the concept of excellence as described above, the corpus of current accreditation standards might need to be revisited. An estimate of the scope of work can be appreciated by reviewing the standards used by six major accreditation systems for medical schools: The Liaison Committee on Medical Education (LCME); the Committee on Accreditation of Canadian Medical Schools (CACMS); the Australian Medical Council (AMC); the General Medical Council (GMC); the World Federation for Medical Education (WFME); and the Conférence Internationale des Doyens et desFacultés de Médecined' Expression Française (CIDMEF): International Association of Francophone Deans and Medical Schools.[17],[18],[19],[20],[21],[22],[23],[24] A general observation is that all six concentrate essentially on the quality of medical education processes with variable consideration for the potential links between these processes and the development of a more efficient, equitable, and sustainable health system and the short- and long-term consequences of their programs on population health. Observation suggests that they also represent somewhat limited assessment of the research and service missions of the schools.

In the document, Functions, and Structure of a Medical School,[17] the LCME proposes 12 standards. In Standard 1, “Mission, planning, organization, and integrity,” includes element 1.1 “Strategic Planning and Continuous Quality Improvement” which requires schools to establish short and long-term programmatic goals, with measurable outcomes used to improve programmatic quality. However, there are no explicit requirements for schools to consider relevant population health challenges in the development of their programmatic goals. In 3.3 “Diversity/Pipeline Programs and Partnerships” it asks schools to engage in practices to achieve mission-appropriate diversity of student and faculty bodies but does not specify whether the mission needs to take into consideration the population health needs.

Under Standard 6, “Competencies, curriculum objectives, and curriculum design,” schools are required to define competencies to be achieved by their graduates, without asking how the competencies are linked to specific population health needs. Standard 7, “Curriculum content,” requires students to apply updated scientific knowledge to act on individual and population health and recognize possible impacts of socio-economic and cultural factors on patients' health. In limiting the social perspective to the formal education program instead of promoting it as a real ethos for the entire school, the opportunity may be missed to encourage teachers, practitioners, and researchers to wrestle with such issues in their respective professional lives and become role models for graduates in their career choices.

The CACMS [18] shares the same 12 standards as the LCME but has added an accreditation element under Standard 1. Element 1.1.1 specifically addresses the social accountability mandate of medical schools and states that “A medical school is committed to address the priority health concerns of the populations it has a responsibility to serve. The medical school's social accountability is articulated in its mission statement; fulfilled in its educational program through admissions, curricular content, and types and locations of educational experiences; evidenced by specific outcome measures.” The CACMS version of Element 3.6 “Diversity/Pipeline Programs and Partnerships” specifically refers to the social accountability mission of schools and requires that schools engage in practices to achieve student and faculty diversity in accordance with their social accountability mission.

Standard 1.1.3 of the AMC states that “The medical education provider consults relevant groups on key issues relating to its purpose, the curriculum, graduate outcomes and governance”.[19] The key issues mentioned are not further detailed and do not explicitly refer to a social accountability role for medical schools. Standards 2.1.2, 2.1.3, and 2.1.4, however, demand that medical schools' purpose addresses indigenous populations' health needs, be defined in consultation with stakeholders, and that schools' teaching, service, and research activities relate to the needs of the populations served. Standard 2.2.1 asks schools to link graduate outcomes with the schools' stated purpose. Standard 1.4.1 requires that the medical education provider use the educational expertise of indigenous peoples in the development and management of the medical program. Specific linkages between indigenous peoples' contribution of educational expertise and the health needs and challenges of indigenous peoples are not specified, though Standard 3.5 requires that curricular content include indigenous health, and Standard 1.6.2 mandates effective partnerships with relevant stakeholders of indigenous health to promote the education and training of medical graduates, recognizing the particular needs of indigenous peoples. Diversity in student and faculty bodies is clearly focused on indigenous representations, with regard to student admission (Standards 7.1.2, 7.2.3), student support (Standard 7.3.3), and faculty recruitment and retention (Standard 1.8.3).

Standards from the GMC [20] do not address the social accountability mission of medical schools. The related document “Outcomes for graduates”[21] does not mention the various aspects of social accountability in medical schools.

The WFME document Global standards for quality improvement of medical education[22],[23] states that the primary goal of medical education is the improvement of people's health. Its 106 standards are clustered into 9 areas and 35 subareas. After a revision in 2015 following the Global Consensus for Social Accountability of Medical Schools, the document reaffirms the importance of strengthening social responsibility in medical education. Although area 1, Mission and outcomes, states that medical schools must respond to the health needs of society and assume consequences for their relationship with health policies, the focus is essentially on educational programs rather than on a comprehensive engagement of schools.

In area 8, Interaction with the health sector, schools are advised to entertain a productive interaction with key stakeholders. No specific standards in the core of the document suggest how to operationalise such interaction for a greater impact on society's health. Standards focus essentially on the educational processes, neglecting to address issues pertaining to the surrounding health environment which may condition career choices of graduates and their geographical settlement and therefore minimize the impact of schools on priority health needs. It might be helpful to medical schools if there were an initial section explaining the expectations of schools to responding to the health needs and challenges of their populations and suggesting potential partnerships to have a greater impact on health.

In its revisited list of standards in 2013,[24] the CIDMEF states in Chapter 1, Mission and objectives, that medical schools must contribute to improving the quality, equity, relevance, and effectiveness of health services. This commitment is further elaborated in Chapter 2, Governance and administration, which recommends that medical schools should share responsibilities in the management of a health-care delivery system in a given territory to demonstrate continuing alignment of their programs with health needs of local populations. A potential benefit of this approach is the settlement of schools' graduates in underserved areas and their embrace of primary care specialties. The CIDMEF document also urges schools' leadership to transform their schools into important actors of the health system. Through these guiding principles, the CIDMEF intends to recogniseexcellence in the social engagement of the entire institution. However, in such a complex area of organizational innovation, standards should be explicitly enunciated and coherently ordered throughout the nine chapters along with definitions and illustrations to enable fair translation of principles into concrete recommendations.

In summary, the LCME, CACMS, AMC, GMC, WFME, and CIDMEF have adapted their standards to a varying extent to address the requirement for medical schools to better respond to the evolving health needs of their societies. While this variability is understandable, there exists an overarching need for accreditation systems to link their various processes to positive outcomes on peoples' health. Additional work remains to be done to strengthen the linkages between accreditation standards, the schools' social accountability and the explicit health needs of the societies and citizens that they serve.

 A Move Toward Future Action



There is a growing worldwide consensus that medical schools should become more socially accountable. Evidence of this can be found in a number of international venues and in significant activity in many regions and at many scales. This activity, however, has not been effectively coordinated. Accreditation systems are slowly evolving, but recommendations for action generally lack the practical specificity to encourage and assess effective and impactful action on the part of medical schools. Accreditation systems and standards are seen as a powerful impetus to advance needed change. However to fulfill this purpose, the corpus of standards and the processes for their adherence must be reframed to properly guide schools toward a better contribution to population health.

In order to link local and global initiatives using accreditation to foster positive social change, two broad areas for action are suggested:

Systematic advocacy for socially accountable accreditation

While accreditation systems aim at ensuring the quality of medical education and by extension the quality of care for populations, they must be attentive to the need for relevance and cost-effectiveness by incorporating the principles of social accountability into their present standards. Inspiration for the design and deployment of such standards can be found in the WHO references,[8] in the 10 strategic directions of the Global Consensus for Social Accountability of Medical Schools [10] as well as in frameworks for evaluating social accountability, such as the ones proposed in the CPU model,[25],[26] the THEnet,[27] ASPIRE,[28] the action plans outlined in the Tunis Declaration,[11] the “Revolution” framework,[29] and the toolkit developed by the International Federation of Medical Students Associations.[30] An engaged panel reflecting the “pentagram partners” [Figure 1] outlined by the WHO should review the state of the art and make recommendations. Mechanisms to animate/vivify such recommendations will need to be developed through relevant collaborations at the global level – as called for in the Tunis Declaration.{Figure 1}

Global harmonisation

The search for excellence in academic institutions is a universal quest. So is the aspiration for free circulation of ideas, talents, and resources. Hence, a certain degree of worldwide harmonisation of the different accreditation systems for medical schools should be considered, with care taken to bring a social accountability lens in recognition that medical schools have an obligation to contribute to universal access to quality care by being health system change agents. Initial work started years ago on the development of international standards [31],[32] needs to be extended. Given the wide variation in educational settings across countries, international standards need to be adjusted to local contexts and cultures.[33] The greatest and most sustainable impact on populations' well-being can only be achieved by making context-specific choices and by optimally using locally available resources. Overarching and universal standards should be assembled by an international process engaging and involving perspectives from the Partnership Pentagram [Figure 1] with options for more specific standards pertinent to different socioeconomic environments.

 Redefining Accreditation Through Engagement



At its best expression, accreditation is institutional peer review. Since the vision outlined above embraces a far more inclusive definition of medical schools and their partnerships than is traditionally the case, it is clear that defining “peer” requires rethinking. Currently, teams visiting medical schools for their accreditation are essentially made of medical professionals. While necessary, this is not sufficient. To warrant more integrated views on how schools fulfill their social obligation, teams should include representatives of other key health stakeholders, including patients and/or communities, as initially outlined by the WHO in the “Partnership Pentagram.”[34] This integration of the communities and other sectors is evolving in various initiatives around the world.[35],[36]

International experiences should be shared and studies conducted on the appropriateness, feasibility, and usefulness of including such team members.

 Conclusion



The social accountability of health professions schools is a topic of considerable interest and activity at both local and global levels. There are many promising factors and trends that provide optimism that concerted global action can dramatically advance the relevance, efficacy, and positive impact of health professions institutions throughout the world. This paper and its supporting organisationsadvocate for stronger links between accreditation systems and health system challenges in order to better contribute toward health for all.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

This paper was been reviewed and all ideas expressed are supported by a number of individuals well versed in the subject under study. They have accepted to be co-signatories. Co-signatories of the paper 'Accrediting excellence for a medical school's impact on population health' are listed in alphabetical order by country and international organization.

 APPENDIX



This paper was been reviewed and all ideas expressed are supported by a number of individuals well versed in the subject under study. They have accepted to be co-signatories. Co-signatories of the paper ''Accrediting excellence for a medical school's impact on population health'' are listed in alphabetical order by country and international organization.

 COUNTRIES



Argentina: Angel Centeno, Vice-Dean, FacultadCiencasBiomedicas, Universidad Austral; Felix Etchegoyen, Dean, University Institute Barcelo Medical School

Australia: Michael Kidd, WONCA, Immediate Past President, Former Dean Flinders University Faculty of Medicine, Nursing and Health Sciences; Richard Murray, Dean of College of Medicine and Dentistry, James Cook University;

Brazil: Florentino Cardoso, President of CONFEMEL-Latin-American-Ibero and Caribbean Medical Confederation, Immediate Past President-Brazilian Medical Association

Canada: Paul Grand'Maison, Vice-Dean, University of Sherbrooke Faculty of Health Sciences; Geneviève Moineau, President and CEO, Association of Faculties of Medicine of Canada; Shawna O'Hearn, Coordinator of the AFMC Working Group on Social Accountability; Julien Poitras, Dean, Medical School, Laval University, Québec; Roger Strasser, Professor of Rural Health, Dean and CEO, Northern Ontario School of Medicine

China: Xiao Haipeng, Vice President, Sun Yat-sen University; Ke Yang, Foreign Associate of Institute of Medicine of National Academies, Peking University; Huang Yingzi, Director, Medical Education Development Centre, Sun Yat-sen University

Chile: Klaus Puschel, Director, School of Medicine, Universidad Catolica, Santiago

Colombia: Liliana Arias, Academic Vice-President, Universidade delle Valle, Cali; Francisco Lamus Lemus, Director EducaciÓn Médica, Profesor Asociado, Facultad de Medicina, Universidad de La Sabana

Egypt: SomayaHosny, Former Dean, Faculty of Medicine, Suez Canal University, Member of the National Authority for Quality Assurance and Accreditation in Education in Egypt (NAQAAE)

France: Jean Sibilia, Président, Conférence des Doyens des Facultés de MédecineFrançaises

Germany: Martin Fischer, Institute of Medical Education, Center for International Health, Ludwig-Maximilians University of Munich

India: Rita Sood, Head, Department of Medicine, All India Institute of Medical Sciences, New Delhi; Avinash Supe, Former Dean, King Edward Memorial Hospital and Seth GordhandasSunderdas Medical College, Mumbai

Indonesia: TitiSavitri, Board of National Education Standards, Ministry of Education and Culture, Republic of Indonesia

Iran: Ali Haeri, Director General, National Council, Medical Schools Educational Affairs, Ministry of Health and Medical Education; FereidounAzizi, Director, Research Institute for Endocrine Sciences

Ireland: Gerard Flahery, National University of Ireland, Galway

Japan: Nobutaro Ban, Vice President, Japan Accreditation Council for Medical Education

Mexico: Melchor Sanchez-Mendiola, Professor of Medical Education, National Autonomous University of Mexico (UNAM) Faculty of Medicine, Mexico City

Pakistan: Rukhsana W Zuberi, Ex-Associate Dean Education, Aga Khan University, Karachi Councilor and Director National Residency Programme South, College of Physicians and Surgeons

Philippines: JoselitoVillaruz, Immediate Past President, Association of Philippine Medical Colleges; Agnès Mejia, Incumbent President, Association of Philippine Medical Colleges; Manuel M. Dayrit, President, Association of Philippine Medical Colleges; Ramon Arcadio, Chair, Commission on Medical Education, Philippine Accrediting Association of Schools, Colleges and Universities

Russia: ZalimBalkizov, Vice-Chair, Association of Russian Medical Societies for Quality Issues in Healthcare and Medical Education; Andrei Svistunov, Vice-Rector of IM Sechenov First State Medical School, Moscow

South Africa: Ben Van Heerden, Chair, Subcommittee for Undergraduate Education and Training, Medical and Dental Professions Board, Health Professions Council of South Africa

Sudan: ZeinKarrar, Chair Sudan Medical Council, Khartoum

Sweden: Stefan Lindgren, President, Swedish Society of Medicine

Spain: Jordi Palés, Director of FundaciÓn EducaciÓn Médica, University of Barcelona

Tunisia: Ali Mtiraoui, Former Dean Medical School of Sousse, President of the University of Sousse

Turkey: IskenderSayek, Association for Evaluation and Accreditation of Medical Education Programs

United Kingdom: Samuel Leinster, Emeritus Professor of Medical Education, Norwich Medical School, University of East Anglia, Senior Adviser at WFME

USA: Daniel S. Blumenthal, Professor Emeritus, Morehouse School of Medicine, Immediate Past President, American College of Preventive Medicine; Arthur Kaufman, Vice-Chancellor, University of New Mexico; Fitzhugh Mullan, Chair, Beyond Flexner Alliance; George Thibault, President, Josiah Macy Jr Foundation

 INTERNATIONAL ORGANIZATIONS



Association of Medical Education in Europe (AMEE): Trevor Gibbs, President

Association of Medical Education in the Eastern Mediterranean Region (AMEEMR): Mohamed Elhassan Abdalla, Chair of Group on Social Accountability

Association of Medical Schools in Europe (AMSE): Peter Dieter, President

ConférenceInternationale des Doyens de faculté de médecined'expressionfrançaise (CIDMEF) [International association of deans of francophone medical schools]: Jean-Luc Dumas, Director General; Gérard Grézinguet, President

Foundation for Advancement of International Medical Education and Research (FAIMER): William Burdick, Vice President for Education; Marta van Zanten, Research Scientist

The Network Towards Unity For Health (Network: TUFH): Henry Campos, Secretary General

Réseau International Francophone pour la ResponsabilitéSociale en Santé (RIFRESS) [Francophone International Network for Social Responsibility in Health]: Ahmed Maherzi, Secretary General

South-East Asia Regional Association for Medical Education (SEARAME): Titi Savitri, President

Training for Health Equity Network (THEnet): Bjorg Palsdottir, Chief Executive Officer

World Organization of Family Doctors (WONCA): Amanda Howe, President

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