By Dr Mohamed Elhassan Abdalla Elsayed, Assistant Professor of Medical Education/College of Medicine-University of Sharjah and Chairman, Group on Social Accountability, Association of Medical Education (EMRO)
Introduction
This blog details work on accreditation standards for social accountability in the Eastern Mediterranean Region. The need for accreditation that addresses social accountability of medical schools is well-established in many seminal reports in the last few years. The EMRO region has set social accountability as one of the strategic directions for medical education, (see Review of Medical Education in the Eastern Mediterranean Region: Challenges, Priorities and a Framework for Action published by the World Health Organization Regional Committee for the Eastern Mediterranean, 62nd session, September 2015).
In developing accreditation standards for social accountability it will be necessary to ensure that there is an enabling health (SDG 3) and education (SDG 4) policy environment at the national level. This could include ensuring that national educational plans for health workers are aligned with national health plans, and that efforts to track graduates are within a lifelong learning framework.
Background
Accreditation is a quality assurance process in education. Historically, the first attempts of accreditation in post-secondary education began in the USA in 1787 when the University of the State of New York was assigned to visit each college in the state to review its work (Harcleroad 1980). In medical education, between 1876 and 1903, representatives of medical colleges in the USA developed a register for medical colleges that met specific agreed-upon standards (El-Khawas, 2001). In 1905, the American Medical Association established its council on medical education, which produced a ten category system for rating medical schools. The first list of medical schools accepted by the association was published in 1907 (El-Khawas, 2001). This continues till the year 1910 when the work by Abraham Flexner (1910) can be considered as the start of accreditation systems that are in use today, including site visits (Boelen, 2002; Flexner, 1910).
In the last two decades, the need for accreditation in medical education has increased, partly in response to changes in medical practice and health care delivery systems (Abdalla, 2008). Other justifications for establishing standards must also be highlighted, including globalisation and the cross-border movement of the health profession (Schwarz, 2000).
Today, more than ninety-two countries are registered with the Foundation for Advancement of International Medical Education and Research (FAIMER) Directory of Organizations that Recognize/Accredit Medical Schools (DORA) (FAIMER, 2009).
There are many definitions for accreditation in medical education; the common feature between all the definitions indicates that it is a process that aims to ensure quality in medical education (Abdalla, 2012). The World Health Organization (WHO) defines accreditation as “a voluntary peer-review process designed to test the educational quality of new and established medical programmes” (WFME, 2005).
The International Institute of Medical Education defines accreditation as “a self-regulatory process by which governmental, non-governmental, voluntary associations or other statutory bodies grant formal recognition to educational programs or institutions that meet stated criteria of educational quality. Educational programs or institutions are measured against certain standards by a review of written information, self-studies, site visits to the educational program, and thoughtful consideration of the findings by a review committee “ (Wojtczak, 2002).
In a publication of the Liaison Committee on Medical Education (LCME), the responsible body for accreditation of medical schools in USA and Canada, the accreditation is defined as “a process of quality assurance in postsecondary education that determines whether an institution or program meets established standards for function, structure, and performance. The accreditation process also fosters institutional and program improvement” (LCME, n.d.).
Purpose/Rationale of Accreditation
The ultimate goal of accreditation is to improve the health status of communities, and it is one way to improve the outcomes of medical schools to match the changing health care delivery systems and produce practitioner who can serve the health needs and expectations of society (Abdalla, 2012).
The accreditation standards direct the development of educational programmes, and guides programme evaluations, (Schwarz, 2000). Recent advances can be found in work led by the World Federation for Medical Education (WFME) in collaboration with the WHO, with the aim to guide quality assurance for medical education to be used worldwide (WHO, 2001). This work resulted in the publication of the document “Basic Medical Education WFME Global Standards for Quality Improvement” in 2003 (WFME 2003) that has been updated in 2015 (WFME, 2015).
Social accountability in Accreditation Standards
Social Accountability is a new frontier in medical education that recognizes the importance of accreditation and provides accreditation guidelines that support the implementation of transformative health workforce education and training (WHO 2013). The Global Consensus for Social Accountability of Medical Schools (GCSA) considers accreditation to be one of the key strategic directions towards social accountability (GCSA, 2010). Accreditation standards can lead schools to recognize the impact of their educational programmes on the societies, and shift the process of delivering these programmes (Boelen, 1999).
Many actors in medical education appreciate that most of the accreditation standards currently used by various accreditation systems are process standards (standards that are related to a medical school’s preparation for performing its functions and the execution of these tasks), while very few are outcome standards (standards pertaining to the results of a programme arising from the three primary purposes of education, research and service ) (Abdalla, 2014). It is essential to address social accountability of medical schools in all accreditation standards (Stefan & Karle, 2011). The recent update of the WFME Basic Medical Education WFME Global Standards for Quality Improvement has explicitly mentioned social accountability in most of the areas it addresses (WFME, 2015).
Accreditation in the Eastern Mediterranean Region
The accreditation process in the Eastern Mediterranean Region started in 2002 with pilot studies supported by the WHO (Mirghani et al., 2005), and was adopted in almost all the countries in the region. Countries can be classified into three groups in terms of the practice of accreditation; i. the majority adopt and adapt the WFME standards such as the Francophone countries, Iran, Iraq and Sudan, ii. some have developed their standards such as the Gulf countries and Pakistan, and iii. others whom we do not have published data regarding the accreditation practice.
In the following section I am going to address examples from five countries to discuss the position of social accountability in their accreditation systems. The countries are Egypt, Iraq, Saudi Arabia, Sudan and the United Arab Emirates.
In Egypt, the National Academic Reference Standards (NARS) is developed by the National Authority for Quality Assurance and Accreditation of Education and used for quality assurance. The standards describe the attributes of the graduates and characteristics of the programmes. The standards do not mention social accountability explicitly, but it has been addressed in some attributes and characteristics.
In Iraq, new guidelines for accreditation was launched for accreditation of medical schools in 2016. The standards follow the WFME with adaptation to the local context and social responsibility is mentioned as a requirement for the medical programme mission.
In Sudan (Sukkar, 2008) the accreditation standards were developed based on the WFME areas and standards. They follow the 2003 version of the standards where social accountability was not mentioned there. However there is a recommendation to update the standards to accommodate the social accountability. The recommendation was set during the development of the Sudan Alliance on Social Accountability (Abdalla & Nuri, 2017). As the WFME updated its standards in 2015 to address social accountability, it is expected that more courtiers in the region are going to upgrade their accreditation standards. Hence social accountability will be more prominent.
In Saudi Arabia and the United Arab Emirates, the accreditation standards in each country are not specific for medical education. The accreditation authorities use a set of generic standards for all higher education programmes but social accountability is not addressed explicitly . The standards address the relation between the programmes and societal needs in different areas such as the mission, the educational programme and the service that can be provided to the society.
Lesson Learned
Although the movement towards establishing an accreditation system is going on in almost all the EMRO countries, individual countries need to make sure that standards that address social accountability are included. The collaborative work is very much needed so countries can benefit from the experience of each other. Regional accreditation standards may be a solution to ensure consistency.
Publication of each country experience and practice in accreditation in relation to social accountability is crucial as this help spread the proper practice.
References
Abdalla, M. E. (2008). Accreditation of Medical Schools, Experience from the Sudan. First Saudi International Conference on Medical Education. Riyadh.
Abdalla, M. E. (2012). Accreditation in Medical Education: Concepts and Practice.
Abdalla, M. E. (2014). Suggested new standards to measure social accountability of medical schools in the accreditation systems. Journal of Case Studies in Accreditation and Assessment, 3. Retrieved from http://www.aabri.com/manuscripts/131505.pdf
Abdalla, M. E., & Nuri, W. (2017). Sudan alliance for Social Accountability of Medical Education.
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Boelen, C. (2002). A new paradigm for medical schools a century after Flexner’s report. Bulletin of the World Health Organization, 80(70), 592–593.
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FAIMER. (2009). Directory of Organizations that Recognize / Accredit Medical Schools (DORA). Retrieved from http://www.faimer.org/dora/index.html
Flexner, A., & Foundation, C. (1910). Medical Education in the United States and Canada, A report to the Carnegie Foundation for the Advancement of Teaching. Carnegie Foundation Bulletin (Vol. No.4).
GCSA. (2010). Golabl Consensus for Social Accounatbility of Medical Schools. Retrieved from http://healthsocialaccountability.sites.olt.ubc.ca/files/2011/01/GCSA-Consensus-Document-English.pdf
LCME. (n.d.). Functions and structure of a Medical School, standards for accreditation of Medical Education Programmes leading to M.D. Degree. Retrieved April 1, 2009, from www.lcme.org
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