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2011; 33: 614–619
Social accountability: The extra leap to
excellence for educational institutions
CHARLES BOELEN
1
& ROBERT WOOLLARD
2
1
International Consultant, France,
2
The University of British Columbia, Canada
Abstract
More than ever are we facing the challenge of providing evidence that what we do responds to priority health needs and
challenges of the ones we intend to serve: patients, citizens, families, communities and the nation at large. Which are those health
needs and challenges? Who defines them? How do medical schools organize themselves to address them through their education,
research and service delivery functions? Principles of social accountability call for an explicit three-tier engagement: identification
of current and prospective social needs and challenges, adaptation of school’s programmes to meet them and verification that
anticipated effects have benefited society. Measurement tools need to be designed and tested to steer development in this
direction, particularly to establish a meaningful relationship between inputs, processes, outputs and impact on health. The Global
Consensus on Social Accountability of Medical Schools provides a unique opportunity to foster collaborative research and
development in an area of great significance for the future of medical education.
Introduction
Aspirations of people and societies for greater transparency,
democracy and participatory management are growing world-
wide. Citizens are increasingly aware of available resources
and more critical about their use in the interest of the public.
The artificial divide between health providers and health
consumers is progressively being replaced by a more open
dialogue between better informed people and experts keen to
discuss choices. Also, with the rapid exchange of information
across borders and the open competition for excellence
induced by globalization, people are more thoughtful about
alternative strategies for a higher level of development for
individuals and society as a whole. A general concern is
increasingly voiced for a fair balance between economic
growth and social justice, with an expectation that health and
education are recognized as legitimate rights for every citizen
anywhere, free of any mercantile handling. Global surveys and
action programmes reckon that one of the major constraints to
achieve ambitious health objectives is related to inadequate
development of human resources for health, in terms of
quality, quantity, diversity and optimal use (World Health
Organization 2006a,b; United Nations 2010). To a certain
extent, all countries are exposed to this phenomenon, leading
policy makers in the health and education sectors to explore
alternative ways for stakeholders to prepare and utilize the
health workforce. In principle, the academic institution is in a
pivotal position to address people and society’s priority health
needs and challenges by designing appropriate educational
programmes and providing their expertise in health system
management for an appropriate use of its graduates.
The complex quest for health
impact
Regarding the health of its citizens, a nation might define its
success in terms of an adequate response to the longing of
societies for improved quality, equity, relevance and effective-
ness in health service delivery. General adherence to those
values is implicit, but a clear definition of each is required for a
better grasp of implications in serving them. Quality in health
Practice points
.The medical school can and should enhance its potential
to influence the planning, production and use of the
health workforce.
.Quality improvement in medical education and evalu-
ation standards to address SA must be revisited and
national accreditation mechanisms established
accordingly.
.The emergence of the GCSA helps define the nature of
academic institutions required to improve their impact
on health.
.The leadership as well as each faculty member can
contribute to making its school more socially account-
able by reorienting education, research and service
delivery programmes towards priority health needs and
challenges of society and ensuring that their efforts have
achieved intended outcomes and impact.
Correspondence: C. Boelen, International consultant in health system and personnel, 585, route d’Excenevex, 74140 Sciez-sur-Le
´man, France.
Tel: (þ33) (0)450 725 141; fax: (þ33) (0)450 725 141; email: boelen.charles@wanadoo.fr
614 ISSN 0142–159X print/ISSN 1466–187X online/11/080614–6 ß2011 Informa UK Ltd.
DOI: 10.3109/0142159X.2011.590248
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care is a person-centred care implying that interventions are
relevant and coordinated to serve the comprehensive needs of
a patient or a citizen. Equity implies that each person in a given
society is given opportunities to benefit from essential health
services. Relevance is present when priority is given to most
prevalent and pressing health concerns and to most vulnerable
individuals and groups in society. Effectiveness is achieved
when the best use is made of available resources to the benefit
of both individuals and the general population.
Assuming that health impact is gauged in reference to the
four values of quality, equity, relevance and effectiveness, how
would a medical school make optimal contributions through
its education, research and service delivery functions? Table 1
illustrates sequential commitment of a school from a ‘plan-
ning’, ‘doing’ to ‘impacting’ phase. For instance, the planning
phase for the education function in respect to equity may be
evidenced by an official statement to address disparity issues
in health, such a better distribution of graduates in under-
served areas. The doing phase may be evidenced by the
design of a curriculum to prepare students to serve in such
areas and reallocation of resources accordingly. The impacting
phase may consist in an active negotiation with concerned
stakeholders to open positions to employ graduates in those
areas.
Table 1 is extracted from a WHO publication promoting the
social accountability (SA) of medical schools (Boelen & Heck
1995). It has been used in different national settings to envision
measurement tools in filling the cells with appropriate
indicators.
The essence of SA is the striving to reach out to go beyond
good intention and well-meaning action and to make the extra
leap in verifying that a significant impact on health system
performance and on people’s health is achieved fully or partly
as a result of one’s interventions. The task of bridging the gap
between an idea and its realization, let alone its impact, is a
complex and challenging one. However, our approach might
be enhanced if we think of the education and health care
systems (and the interaction between them) as complex
adaptive systems. From this perspective, a study commis-
sioned during the Royal Commission on the Future of Health
Care in Canada (2004) (www.healthcoalition.ca/romanow-
report.pdf) provides a useful distinction between complex as
opposed to complicated problems (Glouberman &
Zimmerman 2002).
This distinction leads us to forgo a simple linear quest for
causative influences and then finding an educational ‘silver
bullet’ that will produce the right doctors to practice the right
medicine with the right partners at the right time in the right
place.
We cannot expect a formula to emerge (no matter how
complicated!) that will readily define a pathway and measure
progress of a medical school towards impact on people’s
health. In contrast, the essence of solving complex problems
rests in attempting an integrated, multi-factorial approach that
builds feed-back loops. With adequate attention to the context
in which the school’s education, research and service activities
take place; agreement on the fundamental values that should
underpin them; rigorous and effective peer review; and
collaborative partnerships with other sectors, we might lay
down the conditions for ultimate positive impact on the health
of citizens and populations (Pa
´lsdo
´ttir & Neusy 2010).
Clearly, the health status of populations is not solely, or
even primarily, a result of the health service system. We must
take into account the fact that health is the result of a wide
spectrum of political, economic, cultural, environmental and
biological determinants. Impacting on health therefore implies
coordinated action on those determinants. While outcomes,
such as quality and number of graduates, may be generated by
an educational institution, the impact of those graduates results
from collaborative and convergent action of several stake-
holders, such as health policy makers, health service providers
and practitioners themselves.
Different ways of meeting the
social obligation
Let us assume that any project for establishing a medical
school and training doctors is motivated by an intention to do
the utmost to serve people. Terms such as social responsibility
(SRb), social responsiveness (SRv) and SA are now being seen
in the literature. In a complex world, it is helpful to denote
their specific meanings. The term social responsibility of an
educational institution implies awareness of duties regarding
society and the term social responsiveness the engagement in a
course of actions responding to social needs. The term social
accountability adds a documented justification for the scope
of undertaken actions and a verification that anticipated
outcomes and results have been attained.
A variety of innovative approaches in medical education
have been introduced over the past decades with the explicit
expectation of improving education, and the implicit one that
the better doctors will produce better health. Figure 1 tries to
capture the conceptual leap from ‘implicit’ to ‘explicit’ by
schematizing the relationship of SRb, SRv and SA as different
Table 1. SA grid.
Education Research Service
Values Planning Doing Impacting Planning Doing Impacting Planning Doing Impacting
Relevance
Quality
Cost-effectiveness
Equity
Social accountability: Leap to excellence
615
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gradients on an incremental scale towards the meeting of
social needs. Social needs must be understood in a broad
sense encompassing health needs and challenges expressed
by patients, citizens, families, local communities and the entire
society.
In order to qualify as socially responsible, responsive or
accountable, the mission of a medical school must be to
prepare graduates to best serve the public. SA of medical
schools is defined by WHO as:
the obligation to direct their education, research, and
service activities towards addressing the priority
health concerns of the community, the region, or
nation they have a mandate to serve. The priority
health concerns are to be identified jointly by
governments, health care organizations, health pro-
fessionals and the public (Boelen & Heck 1995).
This general definition stresses the fact that health priorities
are the main focus for action and that those priorities are
collectively set with other health actors.
Figure 1 shows that, under SRb, the first level of scale, the
intention is only implicit as institutional objectives of the
school are not directly derived from a careful analysis of social
needs. The risk of a mismatch between graduates and social
needs is high and cannot be mitigated in the absence of an
evaluation or accreditation mechanism. For instance, in
reference to equity in health, a socially responsible school
might offer courses in public health and epidemiology related
to determinants of poverty and disparity in health but offer
limited exposure to real life situations in the field. A socially
responsive school would move beyond this point and engage
students in community-based activities throughout its curric-
ulum, assess their competences to care for most vulnerable
people and encourage graduates to settle in underserved
areas. A feedback loop from institutional objectives to
outcomes and back to objectives is obvious and remedial
action is fed into the system to improve the response to
social needs.
In case of a socially accountable school, ‘social needs’ are
an integral part of the managerial loop: the school partic-
ipates in needs identification, justifies action programmes
accordingly and verifies whether anticipated outcomes and
results have been attained in satisfying social needs, via
their graduates. A similar commitment bounds its research
and service delivery functions. Following up the example
of equity in health, the school would widen its scope of
duties in participating in a national strategy to improve the
retention of their graduates and their fair distribution
countrywide.
Figure 2 compares the three concepts on the basis of six
items and illustrates a progression on a social obligation scale
climaxing with SA. Although the three concepts are not
locked in tight compartments and not defined by strictly
specific features, it depicts nevertheless an incremental
process and helps all in the system to focus on a desired
level of achievement. In all cases, social needs serve as
references, either implicitly in case of responsibility, or
explicitly in case of responsiveness, or anticipatively in case
of accountability. SA calls the school to be prepared for what
society is likely to be in a foreseeable future in terms of
citizenship, demography, epidemiology, economy as well as
necessary adjustments of health systems and evolving roles of
health professionals. By containing active feedback loops and
capacity for adaptation, the school can participate in careful
study of trends at home and abroad and minimize the risk of
the fortune telling pitfall.
The existence of institutional objectives is a prerequisite to
quality improvement. They will gain in validity if instead of
being defined intuitively by faculty members, they are based
on hard data depicting current and future social needs, and
even more if opinions of informant representatives of society
are taken into account. The relevance of educational
programmes increases by moving from a community orienta-
tion model, whereby theoretical learning prevails, to a
community-based model, whereby learning is taking place in
a variety of health settings reflecting future working environ-
ment of graduates. It is further enhanced under the concept of
SA by making learners fully aware of contextual conditions
and enabling them to knowingly choose a career and settle in
areas of greatest need. ‘Good graduates’ is a loose expression
to define educational outcomes, while compliance to ‘profes-
sionalism’ is more responsive to social needs as graduates are
expected to excel as care providers, support patients’
Social Obligation Scale
Social needs
identified
Implicitly Explicitly Anticipatively
Institutional
objectives
Defined by faculty Inspired from data Defined with society
Educational
programmes
Community-oriented Community-based Contextualized
Quality of
graduates
« Good »
practitioners
Meeting criteria of
professionalism
Health system
change agents
Focus of
evaluation
Process Outcome Impact
Assessors Internal External Health partners
Responsibility Responsiveness Accountability
Figure 2. Social obligation scale.
Social needs
Graduates Institutional objectives
Educational programmes
SA
SRv
SRb
Figure 1. Gradients of response to social needs.
C. Boelen & R. Woollard
616
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autonomy and be advocates of social justice (American Board
of Internal Medicine Foundation et al.2002). In the case of a
socially accountable school, graduates are prepared as
change agents for a more equitable and performing health
system. The more recent concept of ‘service learning’
establishes active learning feedback loops and experience
with accountable learning and practice. This has been
increasingly adopted by accreditors and innovators (Seifer &
Vaughn 2004; LCME 2008; Woollard 2010) who define service
learning as meaning full engagement and assessment of
impact.
Finally, the nature of assessment of social obligation differs
greatly from one concept to the other. In SRb, the main focus is
on processes and assessors are members of the school under
review, while in SRv, the focus is enlarged to include outcomes
in relation to social needs and assessors are external peers. In a
socially accountable school, the scope of assessment is much
widened to incorporate impact on health system performance
and on people’s health status, with health partners including
civil society representatives being part of the assessing and
feedback team.
A socially accountable school will strive for an optimal
match of interventions to current and prospective needs and
challenges of society but will move beyond that to engage
society, with its key stakeholders, to ensure the anticipated
health improvement is eventually attained (Seifer & Vaughn
2004; Woollard 2010). For instance, the likelihood that
graduates will settle in underserved areas is greater if the
school works actively with health authorities on strategies for
attracting them to such areas, compared to a school imposing a
month supervised rotation in a poor community centre, and
even more so to a school offering an optional course on health
disparity.
Recognition of excellence
Aspiring to demonstrate an impact on people’s health should
be regarded as a mark of excellence by the scientific
communities as it is consistent with the evidence-based
approach. Complexity theory allows us to envision the
required relationships and derive assessments of impact even
in the absence of linear causation models. Moreover, as the
performance of institutions, particularly those supported by
public funds, will increasingly be gauged for their benefit to
the general public, one of medical schools ‘greatest challenge
in the future lies in striving for and demonstrating greater
impact on people’s health through tied bonds with society.
This paradigm shift has been favourably accepted by a few
pioneering medical schools (Woollard 2010). It is now being
discussed in national and international circles and increasingly
regarded as a desirable overarching goal. In Canada, for
instance, a white paper published by the federal government
in conjunction with the medical schools suggested SA as a
vision for medical schools in the country (Health Canada
2001). Further, a research project from the Association of
Canadian Medical Colleges based on a rich collection of data
obtained from literature reviews, interviews of experts and
retreats of researchers led to the formulation of 10
recommendations to orient the future of medical education
in Canada. The first recommendation is:
Social responsibility and accountability are core
values underpinning the roles of Canadian physi-
cians and Faculties of Medicine. This commitment
means that, both individually and collectively, phy-
sicians and faculties must respond to the diverse
needs of individuals and communities throughout
Canada, as well as meet international responsibilities
to the global community (Association of Faculties of
Medicine in Canada 2010).
This trend has been confirmed in 2010 by a Global
Consensus for Social Accountability of Medical Schools
(GCSA 2010) that brought together representatives of 130
organizations and individual experts from around the world
with responsibility for health education, professional regula-
tion and policy making to participate for 8 months in a three-
round Delphi process exploring opinions on ways for medical
schools to improve their capacity to respond to future health
challenges in society.
Based on replies, a draft consensus document was
prepared by an international steering committee and further
refined and adopted in a 3-day consensus development
conference with a membership including weighted represen-
tation from all regions of the world (GCSA 2010). While each
nation must adapt it to its own context and priorities, the
resulting Consensus reflects a general agreement on 10
strategic directions to enable a medical school to be socially
accountable (Table 2).
On the whole, the 10 directions embrace a system-wide
scope of issues from identification of health needs to verifi-
cation of the effects of medical schools on those needs, all
driven by the quest of impact on people’s health status. It is a
logical sequence, starting with an understanding of the social
context, an identification of health challenges and needs and
the creation of relationships to act efficiently (Directions 1
and 2). Among the spectrum of required health workforce to
address health needs, the anticipated role and competences of
the doctor are described (Direction 3) serving as a guide to the
education strategy (Direction 4), which the medical school is
called to implement along with consistent research and service
strategies (Direction 5). Standards are required to steer the
Table 2. Ten strategic directions of the global consensus
group.
Direction 1: Anticipating society’s health needs
Direction 2: Partnering with the health system and other stakeholders
Direction 3: Adapting to the evolving roles of doctors and other health
professionals
Direction 4: Fostering outcome-based education
Direction 5: Creating responsive and responsible governance of the
medical school
Direction 6: Refining the scope of standards for education, research
and service delivery
Direction 7: Supporting continuous quality improvement in education,
research and service
Direction 8: Establishing mandated mechanisms for accreditation
Direction 9: Balancing global principles with context specificity
Direction 10: Defining the role of society
Social accountability: Leap to excellence
617
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institution towards a high level of excellence (Directions 6
and 7), which national authorities need to recognize
(Direction 8). While SA is a universal value (Direction 9),
local societies will be the ultimate appraisers of achievements
(Direction 10).
The Global Consensus provides a globally held functional
definition of a socially accountable medical school. The
fulfilment of the 10 strategic directions and the specific
guidelines under each direction may serve as basis to re-
define academic excellence. Central to it is the enhancement
and development of standards, measurement instruments and
accreditation systems, all dedicated to quality improvement in
their impact on the health needs of citizens from the local to
the global scale. This may serve as a foundation upon which to
undertake the many actions defined by bodies throughout the
world.
Implementing SA
The translation of proposed directions by an individual school
or a national organization into concrete policy and operational
actions may follow a stepwise approach including a study of
applicability to the context, an experimentation with evalua-
tion frameworks and an assessment of short-, medium- and
long-term benefits. At first, a study should review the relevance
of the different aspects of SA to a school and its national or
regional context. A fruitful approach to implementation is the
use of appreciative inquiry (Watkins & Stavros 2009) to
identify what the application of SA principles may imply for
changes in use of resources and in the behaviour and
workload for teachers, researchers, practitioners, students
and administration. This should be followed by a project for
designing and testing evaluation tools. Current standards used
to assess the quality of medical education, as promoted by
several medical education organizations, including the World
Federation for Medical Education (WFME 2003), are being
revisited with SA in mind. New standards should be crafted
reflecting SA principles, encompassing inputs (who is trained
for which needs), processes (how is training organized),
outcomes (what do graduates do once in practice) and impact
(how do graduates’ activities improve people’s health).
Therefore, an evaluation framework is needed with a com-
prehensive scope of parameters, inspired from the 10 direc-
tions proposed in the Global Consensus document and from
which standards could be drawn. The CPU model (C for
conceptualization, P for production and U for usability) is an
example of such an evaluation framework (Boelen & Woollard
2009).
It is composed of a cascade of three specific, although
interdependent, clusters of parameters concerning the forma-
tion of health professionals. Parameters in the ‘conceptualiza-
tion’ cluster refer to the collaborative design of the kind of
professionals that society needs and which the system will use
(or should use if the system is to be reformed). The
‘production’ cluster covers the main components of training
and learning to acquire identified competences. The ‘usability’
cluster refers to initiatives taken by the institution to ensure
that its trained professionals are put to their highest and best
use in response to social needs. The term ‘usability’ is
preferred to ‘utilization’ or ‘usefulness’ as graduates may
indeed be utilized and useful as soon as they are employed in
any health setting, even if only some of their acquired
competences are used while ‘usability’ refers to a degree of
concordance between the scope of competences as antici-
pated at time of conceptualization and opportunities to
practice them all in the real working environment. An
international sample of schools has undertaken to design
indicators derived from the CPU model to measure their
compliance with SA principles (Pa
´lsdo
´ttir & Neusy 2010).
Finally, one may question whether a medical school
complying with standards inspired from SA principles will
make a significant difference. The relationship between
medical school innovative work and improved performance
of the health care system, let alone with improved health
status, is difficult to establish. Nevertheless, complexity theory
inspires us to embark on a thoughtful journey by focusing on
the core nature of SA: to help define and engage in directions
and processes that are most likely to lead in that direction.
Conclusion
An exciting field of work opens itself up as aspirations for
greater SA in health and academic institutions are brought to
life through enactment of explicit policies, engagement of
committed policy and fund holders, imaginative research in
developing valid and reliable metrics, creation of adequate
accreditation systems at national or regional level, and the
building of a global consortium to advocate and support norms
and procedures of universal relevance. In 1910, Flexner
intended to revive medical education on strong scientific
grounds and alluded implicitly that it may benefit society. A
century after the publication of his report, the GCSA articulates
explicitly the scope of reforms enabling academic institutions
to improve their impact on people’s health status, essentially
by weaving strong ties with society.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the article.
Notes on contributors
CHARLES BOELEN, MD, MPH, MSc (epidem.), is an independent interna-
tional consultant, formerly coordinator of the World Health Organization
(Geneva headquarters office) programme of human resources for health.
During his 30 years with the WHO, he worked on policies and strategies
worldwide to adapt the health workforce to social needs. He co-chairs the
Global Consensus on Social Accountability of Medical Schools project.
ROBERT WOOLLARD, MD, CCFP, FCFP, has extensive national and
international experience in the field of medical education, ecosystem health
and international community development. He works extensively in the
issue of the social accountability of medical schools and is currently actively
involved in the development of a new national medical school founded on
these principles in Nepal. He is also working in East Africa and Indonesia
on social accountability, primary care and accreditation systems. He is a co-
chair of the Global Consensus for Social Accountability of Medical Schools.
He has been an active practitioner of Family Medicine for 38 years.
C. Boelen & R. Woollard
618
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