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ORIGINAL RESEARCH ARTICLE
Year : 2022 | Volume
: 35
| Issue : 1 | Page : 9-15
Determinants of social accountability for medical schools in Iraq: A qualitative case study
Mohamed Elhassan Abdalla1, Thamer Al HilFi2, Mohammed Al Kurtas3, Taghreed Alhaidari3
1 School of Medicine-University of Limerick, Limerick, Ireland; Group on Social Accountability, Association of Medical Education in Eastern Mediterranean Region (AMEEMR), Baghdad, Iraq
2 WHO Iraq Consultant for Public Health and Health Professional Education, WHO Office, Baghdad, Iraq
3 AlKindy College of Medicine/University of Baghdad, Baghdad, Iraq
Correspondence Address:
Mohamed Elhassan Abdalla
School of Medicine. University of Limerick, Limerick
Iraq
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/efh.EfH_186_19
Background: The mandate of medical schools is to enrich the health system through education, research, and service to satisfy the health needs of the societies they serve. The social accountability (SA) movement aims to intensify the medical school's mission. Although the context of every school is unique, one of the increasingly significant roles of medical education is to develop the indicators that promote SA. The aim of this study is to define the determinants of SA in Iraq using AlKindy College of Medicine/University of Baghdad, Baghdad, Iraq as a case study. Methods: This is a qualitative research using open-ended questions through an online mode; data were analyzed using the content analysis technique. Results: Different themes related to the roles of medical schools, stakeholders, medical schools' mission, curriculum content, research characteristics, service characteristics, enhancers of SA, and accreditation role were identified. The themes are meant to characterize a socially accountable medical school within the context of Iraq. Discussion: The study needs to be replicated in different medical schools to successfully build the national determinants of SA.
Keywords: Determinants, Iraq, social accountability
The mission of medical schools is to train doctors who can meet the requirements of social health;[1],[2] moreover, they have to be accountable for other products, namely the research and the health services.[3] It is a mission that the World Health Organization (WHO) supports by announcing the need of social accountability (SA) in medical education, defined as the 'obligation of the medical schools to direct their education, research, and/or service activities toward addressing the priority health concerns of the community, region, and/or nation they have the mandate to serve. Priority health concerns are to be jointly identified by governments, health-care organizations, health professionals, and the public'.[4]
According to the above definition, which has been adopted according to the global consensus for doctors to be instructed in SA,[5] medical schools need to consult stakeholders, including the relevant society, to share in the identification of the priority health needs and expectations to be addressed for short-and long-term benefits for both the community and medical schools.[6]
Nowadays, the concept of SA is undergoing significant expansion and application. For example, the World Federation for Medical Education (WFME) has recognized the concept as part of the updated standards for the accreditation of medical education programs,[7] and the Network: Towards Unity for Health adopted the Tunisia Declaration for SA in 2017.[8] Another remarkable development in SA is the inclusion of related standards in the National Health Workforce Accounts Handbook developed by the WHO and launched in 2017.[9]
Still, as reported by McCrea and Murdoch-Eaton, even if it were possible to mention all the initiatives to spread the culture of and understanding about SA, more work is needed on translating the concept into real actions related to the curricula and other functions of medical schools.[10] As societies and thus their health needs are different, every country needs to define what determines the SA of its medical and health professional schools, which indicators the schools must then translate into their curricula and other activities.
This study aims to answer the question, what determines the SA of medical schools in the context of Iraq? The objective of the research is to gain insight into the SA of medical schools in Iraq taking AlKindy College of Medicine/University of Baghdad, Baghdad, Iraq as a case study.
The research was approved by the scientific unit and the research ethics committee at AlKindy College of Medicine, University of Baghdad, Baghdad, Iraq in a meeting on 3 September 2018.
MethodsThis example of qualitative research used an online, open-ended questionnaire through SurveyMonkey to collect narrative responses for the questions (apart from the demographic data); the questionnaire was designed with not word limits to the answers by respondents. The questionnaire was used for two reasons: the first that it is intended to collect as much in-depth data as possible about the Determinants of SA for Medical Schools in Iraq and that the study as is planned to extend the study to other medical schools in the country so direct collection of qualitative data will be feasible. The study populations were the faculty members and other stakeholders (Health Authority Leadership, Members of Medical Professional Associations, Members of Civil Society Organisations, Recently Medical Graduates and Medical Student) in the context of AlKindy College of Medicine/University of Baghdad, Baghdad, Iraq is removed for blinding.
The sample for this research is purposive, the maximum variant purposive sampling was used to include all those concerned with the SA of the medical school. The targeted participants were invited by E-mail; information about the study was attached to the E-mail together with a link to the online questionnaire. The first page of the online survey was a consent form, and it revealed to the participant that their agreement to participate in the research would be taken by navigating to the second page of the survey. Follow-up E-mails, phone calls, or SMS were used to increase the response rate.
The questionnaire collected demographic data about the participants and their responses to the following questions:
What are the roles of medical schools regarding SA and community engagement?Who are the primary stakeholders for the medical school's SA that helps in the satisfaction of social health needs?How can the Mission Statement of the medical school reflect its accountability to society?What are the characteristics of the curriculum in medical schools to reflect SA?What are the characteristics of the research conducted by medical schools that will reflect SA?What are the characteristics of the health services to be provided by medical schools that will reflect SA?What are the mechanisms and approaches to enhance the SA of medical schools in Iraq?How can the accreditation process ensure the SA of the schools?To help participants formulate their thoughts about SA, they were provided with the WHO generic definition of SA and a web link to the Global Consensus for SA (GCSA) of Medical Schools together with a summary of the 10 strategic directions for SA.
The online link for the questionnaire was open for 30 days; then, the collected responses were analyzed using the content analysis method. Data were analyzed using QDA Miner Lite, free qualitative data analysis software, to determine the codes, and then the categories and themes were defined from the codes. The analysis was done by one of the first author and reviewed by the other authors independently; discussions were held to reach a consensus when there was disagreement on the codes, themes, and categories. [Table 1] below below is an example of the analysis of one of the questions:
ResultsThe survey was distributed to 99 individuals from different stakeholder groups; 42 responded with a response rate of 42.4% of whom a majority were faculty members.
The sections below present the themes identified for each determinant of SA; the categories related to the themes together with some of the responses are presented in [Table 1].
Regarding the expected roles of medical schools that can reflect SA, four major themes were mentioned: education of future doctors to serve the community, support for the health system, provision of health service to the community, and conduction of research.
The Ministry of Health or health authority and the community (including patients) were identified as the primary stakeholders of medical schools to pursue a socially accountable function, while other stakeholders mentioned were decision makers (other than health authorities) including higher education, nongovernmental organizations, students and graduates, and health professionals and professional bodies.
Responses related to the content of the mission that reflect the SA of medical schools revealed the following important themes to be addressed [Table 2] the graduate qualities and competencies, working to fulfill the local health needs, working as a partner with other sections, and special consideration of the underserved population.
As per the respondent's opinion, the socially accountable curriculum in the college should include the following contents: ethics, professionalism, and patient safety were the top mentioned, followed by public health issues, principles of family medicine, and health system studies. The curriculum should adopt innovative approaches to learning, the content should address social needs, and it should include community engagement. The curriculum orientation should consider all the disciplines and foster evidence-based knowledge.
For the characteristics of research that a socially accountable medical school can feature, the main ones mentioned were that research should address community health problems, and the community should be involved in the planning and conduct of the research.
Among the services that can be tackled by the socially accountable medical school, four main themes were mentioned: service should be affordable and accessible, delivered to people in need of care, planned with stakeholders, and make use of the available resources of the college and university.
When asking about the mechanisms that can enhance SA in Iraq, the responses fall within the following themes: promote involvement of the stakeholders, especially the health services, increase the awareness about SA, develop a powerful accreditation system that includes specific standards for SA, and give consideration to other colleges who have a good record of SA.
The specific roles of the accreditation system to enhance SA were set for developing the standards that serve to develop the process, continuous follow-up, and the consideration of the community satisfaction with the medical school's performance. Below are some of the responses that reflect these categories:
DiscussionThe SA of medical schools has witnessed a great expansion since 1995; it is now one of the indicators for excellence in medical education.[11] Boelen et al. suggested a range of broad indicators and determinants of SA that need to be contextualized by medical schools for better practice of the expected obligation to society.[12] Accordingly, it is important to look at SA as a link between the medical school activity and its context;[13] this is what the results of this study are about.
The main role of medical schools is to enrich the health system's response to the needs of society[11],[14] through good care for research production and health services besides the basic education of students.[3] Those roles were well documented in the above results, although very few respondents mentioned research as the main role.
In general, the mission statements of medical schools vary;[15] the school's activities, not only the processes of education, including expected social roles should refer to what is stated in the mission statement.[16],[17] The challenge usually arises on how to translate the mission into real activities[15] that are important to stakeholders; the responses in this study mentioned the main areas to be addressed by medical schools to be socially accountable in Iraq.
To achieve SA, it is important to define, consult, and have institutional partnership with possible stakeholders for health to uncover all the changes that can help satisfy the priority health needs of the societies involved,[5],[11] especially the Ministry of Health, as is documented in many reports and declarations such as the Edinburgh Declaration.[18] Other examples of an existing progressive collaboration between the medical education and the health services can be traced in the literature.[18],[19],[20]
In general, the stakeholders mentioned in this study are compatible with those defined based on the pentagram suggested by Woollard[13] in addition to students; their opinion can help to refine the satisfaction of society's health needs.[21]
For SA, the curriculum reflects different levels of the social obligation of the medical schools, and the contents and the strategies of learning are among the indicators that echo that obligation.[11],[22] The GCSA calls for adoption of the social determinants of health as one of the directives for the college's activities.[5]
In the social obligation gradient published by Boelen, it is evident that the curriculum that aims to equip graduates with professional competencies falls into the SA category.[11] In addition, the necessity of competencies related to professionalism, ethics, leadership, population health, and health promotion is highlighted in the GCSA,[5] while the results of this research also valued such contents to build a socially accountable medical college in Iraq.
Respondents also mentioned the need for an innovative approach to learning; this is in agreement with the call of the GCSA for the adoption of learning strategies to foster outcome-based education and helps build life-long learners, for example, in the form of problem-solving skills[5] together with the appropriate assessment methods.
For research to be socially accountable, it needs to address the needs of and involve the community as well; this is a breakthrough in research indicators as the challenge in research within the SA arena is that medical schools need to balance between what is needed by the communities and the interest of the traditional academic in research.[17] It is well established that, to have community-based research, it is important to build a partnership with all those involved and not merely to utilize the community setting instead of the laboratory.[3]
Although health service is not a direct responsibility of medical schools, they are among the main players based on the partnership pentagram to satisfy the health needs of society.[13] In regard to the responses of these related to Iraq presented in this study, the GCSA has indicated that the mission of medical schools should incorporate the delivery of health service as inspired by the needs of society.[5]
It is documented in the literature that different perceptions about SA have been expressed by faculty members,[23] so, as mentioned by the respondents in this study, it is crucial to develop faculty attitudes toward SA. In this regard, faculty development experiences directed toward SA have begun to be published[24] and can be used in Iraq.
Another factor essential to the enhancement of SA in Iraq is the involvement of all stakeholders; this is crucial because of the nature of the SA activities and expectations. Medical schools need to realize that they cannot perform the teaching of SA alone; rather, they need to foster like-minded institutional partners.[5],[13]
Periodic review of the curriculum and other activities related to the SA of the medical school is a crucial element to maintain the movement. As mentioned in the GCSA,[5] this is reflected in this study by the need of accreditation for the enhancement of SA. Governance is among the areas that foster SA, as is mentioned in the global consensus but was not mentioned by the respondents to this research.[5]
As was mentioned by the respondents, accreditation plays a major role in SA. Unfortunately, until recently, the accreditation standards were dominated by the process standards rather than the outcome standards that serve the ends of SA.[25] Accreditation is seen as a genuine motive for SA, as indicated in the GCSA,[5] so there are attempts to produce standards and frameworks that fit with SA.[1],[26],[27] Such attempts were crowned by the publication of the WFME standards in 2015 that incorporate the concept in different areas of its standards.[7]
ConclusionThis is the first study attempting to define the determinants of SA for medical schools in Iraq using one college as a case study; the study presented contextualized results that can be validated by other colleges in Iraq. More case studies are needed by other colleges, and a program to set the national determinants of SA for medical schools is crucial; future studies should take into consideration the limitations and lessons learned from this study.
Limitations
The conduction of this study in only one medical college may restrict its generalizability, while another limitation is related to the online data collection; we expect that some of those invited were unable to respond.
Acknowledgment
The research team wishes to extend its thanks and appreciation to the leadership and administration of Al-Kindy College of Medicine and to all faculty members, staff students, and other stakeholders who participated in the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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