How do contextual issues influence socially accountable medical schools?\ud

Socially accountable medical schools deem themselves responsible for the health needs of the communities that they serve. They orientate their education, research and service to the health needs of the population. As a theoretical concept, socially accountable medical schools developed out of attempts for the transformation of medical education. During the 1910s to 1980s there were key reforms in medical education and broader public health from the Flexner review to "Health for All". Developments included decolonisation in less financially resourced countries which led to the need for new health roles. During the 1980s to 2000s Dr Charles Boelen and other colleagues at the World Health Organization developed the theory of socially accountable medical education and socially accountable medical schools. Influential conceptual frameworks developed included the social accountability grid, then the conceptualization, production and utilization grid, the values of social accountability (relevance, equity, cost-effectiveness and quality) and the Towards Unity for Health partnership's model. From the 2000s to 2010s medical schools and global institutions refocused on socially accountability and there was re-interest in measuring and evaluating socially accountable medical schools. A number of initiatives at individual schools and collectively, operationalised social accountability. In the 2010s initiatives included the Lancet's Independent Commission on Health Professional Education for the 21st century and the call for socially accountable medical education to be aligned with accreditation systems. Some of the challenges to implementing social accountability at medical schools included the perceived lack of power of the medical profession and medical schools to address wider systems issues.\ud \ud From my professional experience I observed that many medical schools aspiring to be socially accountable had developed independently from the theoretical concepts of socially accountable medical education. Therefore contextual factors, or external and internal conditions, must have influenced schools to aspire to be socially accountable. From this analysis of the historical and conceptual development of socially accountable schools I hypothesised that there were three key contextual factors that have influenced socially accountable medical schools:\ud \ud • Profile of the local health workforce\ud \ud • Partnerships with the local, state and national health system; and\ud \ud • Partnerships between the medical school and its 'community'.\ud \ud Using a multiple case study approach I explored how contextual issues have influenced social accountability at four medical schools in Australia and the Philippines. I theorised that workforce, health sector partnerships and communities would be strong contextual influences. I interviewed 75 participants including staff, students, health sector representatives and community members. I undertook fieldwork and documentary analysis.\ud \ud I needed to understand how social accountability was interpreted at the schools to appreciate the contextual factors that influenced social accountability at that school. Social accountability was understood in different ways at each school, but there were three common understandings. Firstly, socially accountable medical education was about meeting workforce, community and health needs. Secondly, social accountability was determined by the type of programs the school implemented or, the way the school operated. Thirdly, social accountability was deemed a personal responsibility or value. Nevertheless there are differences between understandings at each school. There was an assumption that social accountability in the context of medical schools and medical education was known and universally understood, yet the term is still open to contention and debate.\ud \ud There were internal and external factors that influenced the activities and outputs of socially accountable medical schools. At Flinders University School of Medicine (FUSOM) the influential contextual factors were: workforce; government policy and funding; Flinders School of Medicine's community engagement policy; the Flinders University remit for difference; The Training for Health Equity and leadership and individual champions. At James Cook University School of Medicine (JCUSOM) there were five contextual factors that had influenced social accountability: the difference of the geographic place and the unique needs of the population of the north of Australia (connected with the participants' understanding of community); the local workforce situation; the impact of government policy; community support for the school; and the shared values and experiences of people, including staff and leaders at both the school and the health sector. There were seven overarching influences, both external and internal factors at Ateneo de Zamboanga School of Medicine (ADZU SOM): regional health; workforce and community needs; placement communities; local officials and politics and peace and order in the face of a regional conflict; religion; limited resources and the values and experiences of a leader. Social accountability at the University of the Philippines, Manila, School of Health Sciences (UPMSHS) was influenced by four contextual factors: the regional workforce and health needs; local politicians and politics; the community and limited resources.\ud \ud In the cross case analysis I found ten contextual factors that influenced social accountability. The strongest contextual factor was the local workforce and health situation which led to innovative educational programs and a research focus on local health issues. Communities may not have comprehended their own influence; however, they were fundamental for socially accountable practices including student placements. Government policy and funding supported socially accountable programs such as rural health initiatives in Australia. While in the Philippines, due to the decentralisation of the health system, the local government and local politicians influenced student placements and graduate employment. The wider institutional environment of their universities affected the culture and the resourcing of programs. In some contexts, resources were required to fund programs and in some contexts lack of resources has spurred innovation. The values and professional experiences of leaders and individuals influenced whether a school's organisational culture was conducive to social accountability. Membership of a coalition of socially accountable medical schools, The Training for Health Equity Network (THEnet) created a community of learning and legitimised local practice. \ud \ud There were two contextual factors that emerged from the cross case analysis and require further investigation: the idea of resisting dominant paradigms of medical education and the health system. All schools also had a culture of resistance to mainstream models of medical education. The resistance or rebellion against dominant paradigms fostered the need for alternative models of medical education that develop the theory of socially accountable medical schools. The health sector, a contextual factor I identified in the literature, was not a direct influence. However the health sector was connected with other contextual factors: individual champions; the workforce situation and resources.\ud \ud A conceptual framework illustrates the seven building blocks for socially accountable medical schools. Practical guidelines based on these building blocks are provided for medical schools. Topics for further research include applying the conceptual framework to medical schools not part of THEnet and developing understandings of how communities would like to work with medical schools. There needs to be further exploration on how medical schools aspiring to be socially accountable are perceived, both internally and externally as "the other" and are challenging dominant paradigms of medical education. This research will assist the medical education community to learn from the experiences of the four case study schools, and will contribute to the development of the theory and practice of socially accountable medical schools.\u