Social accountability in health professionals' training.

With the 100th anniversary of Flexner’s seminal report on medical education, The Lancet published guidelines by a global independent Commission that aimed to establish a 21st-century vision for the education of health professionals. As young doctors, we applaud the Commission for moving beyond professional silos to new models of interprofessional collaboration. But there should be more emphasis on service and social mission in health professionals’ training. WHO defi nes the social accountability of medical training as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve”. Students entering the health professions have strong ideals that must be fostered during training and sustained within systems that encourage us to be change-agents in local and global contexts. Such education must go beyond care for the individual to instil the importance of community advocacy and the ethic of practising in areas of the greatest need. Unfortunately, that goal is far away. Economic factors, such as the high cost of medical education and the commoditisation of health care, have disincentivised practitioners from entering much-needed primary care. In developed countries, underserved areas lack providers; in developing countries, the brain drain has resulted in far worse shortages. Moreover, the existing education that places disproportionate focus on basic science unbalances the curriculum, with over 90% of students reporting that they are not suffi ciently trained in public health and problems facing their community. As students go through training, idealism erodes, with an accompanying decline in service orientation and empathy for patients. The centennial of Flexner’s report is the time to make bold changes and redirect the focus of health professionals’ education towards social accountability. Using the training of doctors as our example, we propose fi ve steps for every medical school and healthprofessional training programme to help align their training with societal need. First, an explicit social mission needs to be established. A recent report on US medical schools showed that having social accountability as the guiding principle aff ected every step of training, from recruitment to curriculum to career. Regulatory bodies should measure social accountability as a metric for excellence and accreditation. Second, community learning and service should be integrated into the curriculum. Students who spend more time in community settings have a much higher rate of returning there to practise. For doctors to truly advocate for their communities, an irreplaceable part of training needs to be understanding and addressing community concerns. Third, the importance of primary care deserves particular emphasis. Although the centrality of primary health care has been recognised since the declaration of Alma-Ata over 30 years ago, too few young doctors are entering primary care. Some institutions, such as the Walter Sisulu Medical School in South Africa, teach fi rst-year students to incorporate community-oriented primary care principles by visiting family homes, traditional healers, and community health centres. Most graduates are practising primary care in rural and peri-urban areas. Fourth, there needs to be a service option in exchange for free medical education. The concept of debt repayment in exchange for service has existed in virtually every country as compulsory national service or loan repayment options. Early data from compulsory programmes in 70 countries showed promising results. One example is Cuba’s Latin American School