Background

The medical profession has a long-standing tradition of addressing social issues that affect public health—a mission that can be traced as far back as the time of Hippocrates. Indeed, this commitment is deeply embedded in the core of the profession and is actively underscored across all medical schools.

The World Health Organization (WHO) defines social accountability in the field of medical education as the responsibility to focus education, research, and service provisions based on the health needs of the communities, regions, and countries where doctors are supposed to serve (1). The WHO has also introduced social accountability with four criteria of justice, quality, effectiveness, and relevancy in service delivery (2, 3). Hence, social accountability should emphasize compliance with professional standards and meeting society's expectations by providing equal opportunities for health care for all, addressing problems related to society, as well as ensuring the cost-effectiveness of health care services (4-6).

In parallel with global changes and developments, Iran's medical education system underwent major transformations. The turning point of these changes—specifically the shift toward addressing societal needs—dates to 1986, when the Ministry of Health and Medical Education was established.

The introduction of community and preventive medicine rotations along the clerkship and internship phases marked another significant step toward accountable medical education. Subsequently, the fourth phase of the “Health System Evolution Program” in
2013 served as a foundational initiative which brought substantial effects to the broader effort of aligning the medical education system with societal needs.

At present, addressing the issue of social accountability in medical education appears to be unavoidable. Based on the findings of our study on social accountability of medical schools in Iran, we suggest the following steps to run a social accountable program of medical education:

Policy recommendation

Steps to provide social accountability in medical education

• Addressing the health needs of society through producing science that is responsive to those needs, training skilled human resources, and delivering effective services.
• Focusing on the framework in which the educational system leads the health system, encompassing education, research, and service delivery. With a curriculum focused to societal needs, graduates are anticipated to be proactive in delivering services, while research is developed to address community requirements alongside education. As a macro-level step, policymaking should be centrally aligned with the needs of society, reflecting the country's centralized education system. This involves performing continuous and dynamic needs assessments to account for changes over time. Based on these assessments, stakeholders should be trained in accordance with the necessary needs. Ultimately, comprehensive planning should be undertaken to address the identified needs, ensuring that all aspects and subsets of the organization are included to enhance accountability in education and ultimately ameliorate the health system.
• Achieving social accountability in education requires involvement of all organizational components. To this end, the system needs to ensure the presence of knowledgeable, expert, and capable managers, as well as competent trainers—including academic faculty members with the requisite skills and qualifications—alongside the necessary resources. Adequate resources of departments can provide the facilities and equipment required to support accountable education. Further, faculty members should be familiar with societal needs and actively engaged with them in some capacity. Equally important is an institutional attitude that prioritizes responsiveness to community needs, which serves as a key driver of educational accountability. This step can be regarded as a meso-level initiative, implemented within medical schools.
• Once the foundations are in place, training can be planned in alignment with community needs. In this respect, after identifying the health needs of society, these priorities are incorporated into the curriculum—which is itself designed around expected competencies and qualifications—with courses and training programs subsequently developed based on those identified topics.
• Thereafter, the conditions for education in community settings—such as the provision of authentic environments—need to be established. The training environment should reflect real-world conditions, including health comprehensive service centers, outpatient clinics, and other settings relevant to public health. Ultimately, the philosophy underlying curriculum development should be outcome-oriented, with a focus on addressing people's health needs, to accomplish social accountability. These steps can be considered as the meso-level and macro-level respectively.
• The educational system should be appraised through evaluating the accreditation of the organization and the responsive training program. In the standards of institutional accreditation and program accreditation, social accountability should be addressed and placed among the most essential criteria. The inclusion of standards related to responsive education in institutional and program accreditation can guide and motivate organizations to develop educational goals aimed at social accountability—particularly when accreditation outcomes are linked to incentive allocation. It should be demonstrated that education, research, and responsive service delivery have been able to generate a measurable impact on community health. To ensure this effectiveness, the data of the health system should be continuously reviewed and analyzed (7-10).

Obstacles to the implementation of education with social accountability

Barriers to implementing social accountability in medical education include limited awareness among stakeholders and faculty members regarding its concept as well as significance, insufficient infrastructure for implementation, resistance to change and adherence to traditional educational methods, excessive responsibilities assigned to faculty members, inadequate motivation, along with a shortage of suitable training settings—such as rural field placements.

Conclusion

As a first step toward implementing socially accountable medical education, we should address weaknesses that can be resolved through simple, cost-effective interventions. These include establishing committees or working groups for accountable education within medical schools, organizing regular workshops for various beneficiary and stakeholder groups, as well as supporting the design of programs that promote social accountability—such as early community exposure.

It is also essential to train suitable human resources, identify and prioritize the health needs of the community, and gather the necessary evidence to deliver effective services. Curriculum should be designed around competencies and outcomes, with university courses developed in accordance with these frameworks and the health needs of society. All elements of the medical schools should participate in the development of the educational program so that the implementation of the program is possible. For the program to be feasible, all organizational managers should be involved in formulating the faculty's mission, to secure their support along the implementation phase.

Eventually, the program should undergo evaluation and accreditation. Its effectiveness in enhancing service delivery to fulfil the health needs of the population should be assessed, and the resulting feedback should be continuously integrated into the curriculum as well as course plans.