Social responsiveness: The key ingredient to achieve social accountability in education and health care.

While social accountability (SA) is regarded as an obligation or mandate for medical school administration, it runs the danger of becoming a bureaucratic checkbox. Compassion which leads to social responsiveness (SR), in contrast, is often recognized as an individual characteristic, detached from the public domain. The two, however, complement each other in practice. Institutions must be truly socially accountable, which is possible if there is spontaneous SR to the needs, and is fueled by compassion. Compassion in this article is defined as a "feeling for other people's sufferings, and the desire to act to relieve the suffering." Compassion has a long history, whereas SA is more recently described concept that follows the historical development of social justice. SR is the moral or ethical duty of an individual to behave in a way that benefits society. Not everyone feels the need to do something for others. Even if the need is felt, there may be a lack of will to act for the needs or to act effectively to fulfill the needs of society. The reasons are many, some visible and others not. SR provides the basis for being compassionate; hence, medical schools need to include SR as a criterion in their admissions process for student recruitment and inculcate compassion in health professions education and health care. By fostering SR and engaging compassion and self-compassion to achieve SA, we can humanize medical education systems and health care.

The Limerick Declaration on Rural Health Care 2022.

The 19th World Rural Health Conference, hosted in rural Ireland and the University of Limerick, with over 650 participants coming from 40 countries and an additional 1600 engaging online, has carefully considered how best rural communities can be empowered to improve their own health and the health of those around them. The conference also considered the role of national health systems and all stakeholders, in keeping with the commitments made through the Sustainable Development Goals and the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being. This conference declaration, the Limerick Declaration on Rural Healthcare, is designed to inform rural communities, academics and policymakers about how to achieve the goal of delivering high quality health care in rural and remote areas most effectively, with a particular focus on the Irish healthcare system. Congruent with current evidence and best international practice, the participants of the conference endorsed a series of recommendations for the creation of high quality, sustainable and cost-effective healthcare delivery for rural communities in Ireland and globally. The recommendations focused on four major themes: rural healthcare needs and delivery, rural workforce, advocacy and policy, and research for rural health care. Equal access to health care is a crucial marker of democracy. Hence, we call on all governments, policymakers, academic institutions and communities globally to commit to providing their rural dwellers with equitable access to health care that is properly resourced and fundamentally patient-centred in its design.

Addressing rural and Indigenous health inequities in Canada through socially accountable health partnerships.

BACKGROUND: There are few examples of the practical application of the concepts of social accountability, as defined by the World Bank and WHO, to health system change. This paper describes a robust approach led by First Nations Health Authority and the Rural Coordination Centre of British Columbia. This was achieved using partnerships in British Columbia, Canada, where the health system features inequities in service and outcomes for rural and Indigenous populations. Social accountability is achieved when all stakeholders come together simultaneously as partners and agree on a path forward. This approach has enabled socially accountable healthcare, effecting change in the healthcare system by addressing the needs of the population. INNOVATION: Our innovative approach uses social accountability engagement to counteract persistent health inequities. This involves an adaptation of the Boelen Health Partnership model (policymakers, health administrators, health professionals, academics and community members) extended by addition of linked sectors (eg, industry and not-for-profits) to the 'Partnership Pentagram Plus'. We used appreciative inquiry and deliberative dialogue focused on the rural scale and integrating Indigenous ways of knowing along with western scientific traditions ('two-eyed seeing'). Using this approach, partners are brought together to identify common interests and direction as a learning community. Equitable engagement and provision of space as 'peers' and 'partners' were key to this process. Groups with varying perspectives came together to create solutions, building on existing strengths and new collaborative approaches to address specific issues in the community and health services delivery. A resulting provincial table reflecting the Pentagram Plus model has fostered policies and practices over the last 3 years that have resulted in meaningful collaborations for health service change. CONCLUSION: This paper presents the application of the 'Partnership Pentagram Plus' approach and uses appreciative inquiry and deliberative dialogue to bring about practical and positive change to rural and Indigenous communities.

Distributed education enables distributed economic impact: the economic contribution of the Northern Ontario School of Medicine to communities in Canada.

BACKGROUND: Medical schools with distributed or regional programs encourage people to live, work, and learn in communities that may be economically challenged. Local spending by the program, staff, teachers, and students has a local economic impact. Although the economic impact of DME has been estimated for nations and sub-national regions, the community-specific impact is often unknown. Communities that contribute to the success of DME have an interest in knowing the local economic impact of this participation. To provide this information, we estimated the economic impact of the Northern Ontario School of Medicine (NOSM) on selected communities in the historically medically underserviced and economically disadvantaged Northern Ontario region. METHODS: Economic impact was estimated by a cash-flow local economic model. Detailed data on program and learner spending were obtained for Northern Ontario communities. We included spending on NOSM's distributed education and research programs, medical residents' salary program, the clinical teachers' reimbursement program, and spending by learners. Economic impact was estimated from total spending in the community adjusted by an economic multiplier based on community population size, industry diversity, and propensity to spend locally. Community employment impact was also estimated. RESULTS: In 2019, direct program and learner spending in Northern Ontario totalled $64.6 M (million) Canadian Dollars. Approximately 76% ($49.1 M) was spent in the two largest population centres of 122,000 and 165,000 people, with 1-5% ($0.7 M - $3.1 M) spent in communities of 5000-78,000 people. In 2019, total economic impact in Northern Ontario was estimated to be $107 M, with an impact of $38 M and $36 M in the two largest population centres. The remaining $34 M (32%) of the economic impact occurred in smaller communities or within the region. Expressed alternatively as employment impact, the 404 full time equivalent (FTE) positions supported an additional 298 FTE positions in Northern Ontario. NOSM-trained physicians practising in the region added an economic impact of $88 M. CONCLUSIONS: By establishing programs and bringing people to Northern Ontario communities, NOSM added local spending and knowledge-based economic activity to a predominantly resource-based economy. In an economically deprived region, distributed medical education enabled distributed economic impact.

Plan, recruit, retain: a framework for local healthcare organizations to achieve a stable remote rural workforce.

BACKGROUND: Recruiting and retaining a skilled health workforce is a common challenge for remote and rural communities worldwide, negatively impacting access to services, and in turn peoples' health. The research literature highlights different factors facilitating or hindering recruitment and retention of healthcare workers to remote and rural areas; however, there are few practical tools to guide local healthcare organizations in their recruitment and retention struggles. The purpose of this paper is to describe the development process, the contents, and the suggested use of The Framework for Remote Rural Workforce Stability. The Framework is a strategy designed for rural and remote healthcare organizations to ensure the recruitment and retention of vital healthcare personnel. METHOD: The Framework is the result of a 7-year, five-country (Sweden, Norway, Canada, Iceland, and Scotland) international collaboration combining literature reviews, practical experience, and national case studies in two different projects. RESULT: The Framework consists of nine key strategic elements, grouped into three main tasks (plan, recruit, retain). Plan: activities to ensure that the population's needs are periodically assessed, that the right service model is in place, and that the right recruits are targeted. Recruit: activities to ensure that the right recruits and their families have the information and support needed to relocate and integrate in the local community. Retain: activities to support team cohesion, train current and future professionals for rural and remote health careers, and assure the attractiveness of these careers. Five conditions for success are recognition of unique issues; targeted investment; a regular cycle of activities involving key agencies; monitoring, evaluating, and adjusting; and active community participation. CONCLUSION: The Framework can be implemented in any local context as a holistic, integrated set of interventions. It is also possible to implement selected components among the nine strategic elements in order to gain recruitment and/or retention improvements.

Training for impact: the socio-economic impact of a fit for purpose health workforce on communities.

Across the globe, a "fit for purpose" health professional workforce is needed to meet health needs and challenges while capitalizing on existing resources and strengths of communities. However, the socio-economic impact of educating and deploying a fit for purpose health workforce can be challenging to evaluate. In this paper, we provide a brief overview of six promising strategies and interventions that provide context-relevant health professional education within the health system. The strategies focused on in the paper are:1. Distributed community-engaged learning: Education occurs in or near underserved communities using a variety of educational modalities including distance learning. Communities served provide input into and actively participate in the education process.2. Curriculum aligned with health needs: The health and social needs of targeted communities guide education, research and service programmes.3. Fit for purpose workers: Education and career tracks are designed to meet the needs of the communities served. This includes cadres such as community health workers, accelerated medically trained clinicians and extended generalists.4. Gender and social empowerment: Ensuring a diverse workforce that includes women having equal opportunity in education and are supported in their delivery of health services.5. Interprofessional training: Teaching the knowledge, skills and attitudes for working in effective teams across professions.6. South-south and north-south partnerships: Sharing of best practices and resources within and between countries.In sum, the sharing of resources, the development of a diverse and interprofessional workforce, the advancement of primary care and a strong community focus all contribute to a world where transformational education improves community health and maximizes the social and economic return on investment.

Rural Health Care Access and Policy in Developing Countries.

Compared to their urban counterparts, rural and remote inhabitants experience lower life expectancy and poorer health status. Nowhere is the worldwide shortage of health professionals more pronounced than in rural areas of developing countries. Sub-Saharan Africa (SSA) includes a disproportionately large number of developing countries; therefore, this article explores SSA in depth as an example. Using the conceptual framework of access to primary health care, sustainable rural health service models, rural health workforce supply, and policy implications, this article presents a review of the academic and gray literature as the basis for recommendations designed to achieve greater health equity. An alternative international standard for health professional education is recommended. Decision makers should draw upon the expertise of communities to identify community-specific health priorities and should build capacity to enable the recruitment and training of local students from underserviced areas to deliver quality health care in rural community settings.

Putting communities in the driver's seat: the realities of community-engaged medical education.

"Community" has featured in the discourse about medical education for over half a century. This discourse has explored relationships between medical education programs and communities in community-oriented medical education and community-based medical education and, in recent years, has extended to community-engaged medical education (CEME). This Perspective explores the developing focus on "community" in medical education, describes CEME as a concept, and presents examples of CEME in action at Flinders University School of Medicine (Australia), the Northern Ontario School of Medicine (Canada), and Ateneo de Zamboanga University School of Medicine (Philippines).The authors describe the ways in which CEME, which features active community participation, can improve medical education while meeting community needs and advancing national and international health equity agendas. They suggest that CEME can redefine student learning as taking place at the center of the partnership between communities and medical schools. They also consider the challenges of CEME and caution that criteria for community engagement must be sensitive to cultural variations and to the nature of the social contract in different sociocultural settings.The authors argue that CEME is effective in producing physicians who choose to practice in rural and underserved areas. Further research is required to demonstrate that CEME contributes to improved health, and ultimately health equity, for the populations served by the medical school.

The economic contribution of the Northern Ontario School of Medicine to communities participating in distributed medical education.

INTRODUCTION: The economic contribution of medical schools to major urban centres can be substantial, but there is little information on the contribution to the economy of participating communities made by schools that provide education and training away from major cities and academic health science centres. We sought to assess the economic contribution of the Northern Ontario School of Medicine (NOSM) to northern Ontario communities participating in NOSM's distributed medical education programs. METHODS: We developed a local economic model and used actual expenditures from 2007/08 to assess the economic contribution of NOSM to communities in northern Ontario. We also estimated the economic contribution of medical students or residents participating in different programs in communities away from the university campuses. To explore broader economic effects, we conducted semistructured interviews with leaders in education, health care and politics in northern Ontario. RESULTS: The total economic contribution to northern Ontario was $67.1 million based on $36.3 million in spending by NOSM and $1.0 million spent by students. Economic contributions were greatest in the university campus cities of Thunder Bay ($26.7 million) and Sudbury ($30.4 million), and $0.8-$1.2 million accrued to the next 3 largest population centres. Communities might realize an economic contribution of $7300-$103 900 per pair of medical learners per placement. Several of the 59 interviewees remarked that the dollar amount could be small to moderate but had broader economic implications. CONCLUSION: Distributed medical education at the NOSM resulted in a substantial economic contribution to participating communities.

INTRODUCTION: Les écoles de médecine peuvent apporter des avantages économiques importants aux grands centres urbains. On n'en sait guère toutefois sur l'apport économique, pour les communautés participantes, des écoles qui offrent des cours et de la formation hors des grandes villes et loin des centres universitaires des sciences de la santé. Nous avons voulu évaluer la contribution économique de l'École de médecine du Nord de l'Ontario (EMNO) aux communautés qui participent à ses programmes d'apprentissage distribué. MÉTHODES: Nous avons créé un modèle économique local et utilisé les dépenses réelles de 2007/08 pour évaluer l'apport économique de l'EMNO aux communautés du Nord de l'Ontario. Nous avons aussi estimé l'apport économique des étudiants en médecine ou des médecins résidents qui participent aux divers programmes offerts dans les communautés éloignées des campus de l'université. Enfin, pour explorer les répercussions économiques plus vastes, nous avons effectué des entrevues semi-structurées auprès de chefs de file des milieux de l'éducation, des soins de santé et de la politique dans le Nord de l'Ontario. RÉSULTATS: L'apport économique total de l'EMNO s'est chiffré à 67,1 millions de dollars (dépenses de l'École, 36,3 millions; dépenses des étudiants, 1,0 million). L'apport économique a été le plus important pour les villes qui hébergent un campus de l'université, soit Thunder Bay (26,7 millions) et Sudbury (30,4 millions), les 3 centres suivants en importance bénéficiant d'un apport de 0,8 à 1,2 million de dollars. Les communautés peuvent réaliser des bénéfices économiques de 7 300 $ à 103 900 $ par paire d'apprenants en médecine par placement. Plusieurs des 59 personnes interviewées ont souligné que le montant des contributions, en argent, peut être assez petit ou moyen, mais que les répercussions économiques se font sentir à plus grande échelle. CONCLUSION: L'éducation médicale distribuée à l'EMNO a apporté une contribution économique substantielle aux communautés participantes.

From the community to the classroom: the Aboriginal health curriculum at the Northern Ontario School of Medicine.

More undergraduate medical education programs are including curricula concerning the health, culture and history of Aboriginal people. This is in response to growing international recognition of the large divide in health status between Aboriginal and non-Aboriginal people, and the role medical education may play in achieving health equity. In this paper, we describe the development and delivery of the Aboriginal health curriculum at the Northern Ontario School of Medicine (NOSM). We describe a process for curriculum development and delivery, which includes ongoing engagement with Aboriginal communities as well as faculty expertise. Aboriginal health is delivered as a core curriculum, and learning is evaluated in summative assessments. Aboriginal health objectives are present in 4 of 5 required courses, primarily in years 1 and 2. Students attend a required 4-week Aboriginal cultural immersion placement at the end of year 1. Resources of Aboriginal knowledge are integrated into learning. In this paper, we reflect on the key challenges encountered in the development and delivery of the Aboriginal health curriculum. These include differences in Aboriginal and non-Aboriginal knowledge; risk of reinforcing stereotypes in case presentations; negotiation of curricular time; and faculty readiness and development. An organizational commitment to social accountability and the resulting community engagement model have been instrumental in creating a robust, sustainable program in Aboriginal health at NOSM.

Transforming health professional education through social accountability: Canada's Northern Ontario School of Medicine.

BACKGROUND: The Northern Ontario School of Medicine (NOSM) has a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario. NOSM recruits students from Northern Ontario or similar backgrounds and provides Distributed Community Engaged Learning in over 70 clinical and community settings located in the region, a vast underserved rural part of Canada. METHODS: NOSM and the Centre for Rural and Northern Health Research (CRaNHR) used mixed methods studies to track NOSM medical learners and dietetic interns, and to assess the socioeconomic impact of NOSM. RESULTS: Ninety-one percent of all MD students come from Northern Ontario with substantial inclusion of Aboriginal (7%) and Francophone (22%) students. Sixty-one percent of MD graduates have chosen family practice (predominantly rural) training. The socioeconomic impact of NOSM included new economic activity, more than double the School's budget; enhanced retention and recruitment for the universities and hospital/health services; and a sense of empowerment among community participants attributable in large part to NOSM. DISCUSSION: There are signs that NOSM is successful in graduating health professionals who have the skills and desire to practice in rural/remote communities and that NOSM is having a largely positive socioeconomic impact on Northern Ontario.

Context counts: training health workers in and for rural and remote areas.

Access to well trained and motivated health workers is the major rural health issue. Without local access, it is unlikely that people in rural and remote communities will be able to achieve the Millennium Development Goals. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: (i) a rural background; (ii) positive clinical and educational experiences in rural settings as part of undergraduate medical education; and (iii) targeted training for rural practice at the postgraduate level. This paper presents evidence for policy initiatives involving the training of medical students from, in and for rural and remote areas. We give examples of medical schools in different regions of the world that are using an evidence-based and context-driven educational approach to producing skilled and motivated health workers. We demonstrate how context influences the design and implementation of different rural education programmes. Successful programmes have overcome major obstacles including negative assumptions and attitudes, and limitations of human, physical, educational and financial resources. Training rural health workers in the rural setting is likely to result in greatly improved recruitment and retention of skilled health-care providers in rural underserved areas with consequent improvement in access to health care for the local communities.

When a community hospital becomes an academic health centre.

With the burgeoning role of distributed medical education and the increasing use of community hospitals for training purposes, challenges arise for undergraduate and postgraduate programs expanding beyond traditional tertiary care models. It is of vital importance to encourage community hospitals and clinical faculty to embrace their roles in medical education for the 21st century. With no university hospitals in northern Ontario, the Northern Ontario School of Medicine and its educational partner hospitals identified questions of concern and collaborated to implement changes. Several themes emerged that are of relevance to any medical educational program expanding beyond its present location. Critical areas for attention include the institutional culture; human, physical and financial resources; and support for educational activities. It is important to establish and maintain the groundwork necessary for the development of thriving integrated community-engaged medical education. Done in tandem with advocacy for change in funding models, this will allow movement beyond the current educational environment. The ultimate goal is successful integration of university and accreditation ideals with practical hands-on medical care and education in new environments.

Canada's new medical school: The Northern Ontario School of Medicine: social accountability through distributed community engaged learning.

Like many rural regions around the world, Northern Ontario has a chronic shortage of doctors. Recognizing that medical graduates who have grown up in a rural area are more likely to practice in the rural setting, the Government of Ontario, Canada, decided in 2001 to establish a new medical school in the region with a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario. The Northern Ontario School of Medicine (NOSM) is a joint initiative of Laurentian University and Lakehead University, which are located 700 miles apart. This paper outlines the development and implementation of NOSM, Canada's first new medical school in more than 30 years. NOSM is a rural distributed community-based medical school which actively seeks to recruit students into its MD program who come from Northern Ontario or from similar northern, rural, remote, Aboriginal, Francophone backgrounds. The holistic, cohesive curriculum for the MD program relies heavily on electronic communications to support distributed community engaged learning. In the classroom and in clinical settings, students explore cases from the perspective of physicians in Northern Ontario. Clinical education takes place in a wide range of community and health service settings, so that the students experience the diversity of communities and cultures in Northern Ontario. NOSM graduates will be skilled physicians ready and able to undertake postgraduate training anywhere, but with a special affinity for and comfort with pursuing postgraduate training and clinical practice in Northern Ontario.