COVID-19 fosters social accountability in medical education


name here
Richard Murray
1 MBBS, MPHTM, Pro Vice Chancellor

name here
Fortunato Cristobal
2 MD, Dean

name here
Shrijana Shrestha
3 PhD, Dean

name here
Filedito D Tandinco
4 MD, Dean ORCID logo

name here
Jan M De Maeseneer
5 PhD, Director ORCID logo

name here
Sarita Verma
6 MD, Dean, President and CEO

name here
Shafik Dharamsi
7 PhD, Senior Advisor to the Provost

name here
Sara Willems
8 PhD, Professor

name here
Arthur Kaufman
9 MD, Professor and Vice Chancellor

name here
Björg Pálsdóttir
10 MPA, Chief Executive Officer

name here
Andre-Jacques Neusy
11 MD, Senior Director

name here
Sarah Larkins
12 PhD , Dean * ORCID logo


*Prof Sarah Larkins


1 Division of Health and Medicine, James Cook University, Douglas, Qld 4811, Australia

2 Ateneo de Zamboanga School of Medicine, Zamboanga, Mindanao, Philippines

3 Patan Academy of Health Sciences, Patan, Nepal

4 School of Health Sciences, University of the Philippines, Manila, Palo, Leyte, Philippines

5 WHO Collaborating Centre on Family Medicine and Primary Health Care; and Department of Public Health and Primary Care, Gent University, Corneel Heymanslaan, B-9000 Gent, Belgium

6 Northern Ontario School of Medicine, Thunder Bay, Ontario P7B 5E1, Canada

7 New Mexico State University, Las Cruces, NM 88003, USA

8 Department of Public Health and Primary Care, Gent University, Corneel Heymanslaan, B-9000 Gent, Belgium

9 School of Medicine, University of New Mexico, MSC09 5040, Albuquerque, NM 87131, USA

10, 11 Training for Health Equity Network (THEnet), 142 West 73rd Street, New York City, NY 10023, USA

12 College of Medicine and Dentistry, James Cook University, Douglas, Qld 4811, Australia


5 May 2022 Volume 22 Issue 2


RECEIVED: 4 July 2021

REVISED: 16 November 2021

ACCEPTED: 11 April 2022


Murray R, Cristobal F, Shrestha S, Tandinco FD, De Maeseneer JM, Verma S, Dharamsi S, Willems S, Kaufman A, Pálsdóttir B, Neusy A, Larkins S.  COVID-19 fosters social accountability in medical education. Rural and Remote Health 2022; 22: 6998.



As a commentary for which no new data were collected this manuscript is exempt from requiring Ethics Review.

This work is licensed under a Creative Commons Attribution 4.0 International Licence


The COVID-19 pandemic has highlighted embedded inequities and fragmentation in our health systems. Traditionally, structural issues with health professional education perpetuate these. 
COVID-19 has highlighted inequities, but may also be a disruptor, allowing positive responses and system redesign. Examples from health professional schools in high and low- and middle-income countries illustrate pro-equity interventions of current relevance.
We recommend that health professional schools and planners consider educational redesign to produce a health workforce well equipped to respond to pandemics and meet future need.


community-based education, COVID-19, medical education, primary health care, social accountability; social mission.

full article:

Health professionals for a pandemic response

Health professionals have found themselves at the global frontline of the COVID-19 pandemic. An acute global shortage of appropriately trained health professionals and equipment to handle a pandemic is apparent. Clinical training has not prepared graduates well for public health emergencies, and health professionals at the coalface have confronted the uncertainty and anxiety provoked by COVID-191. Here, we discuss the impact of the COVID-19 pandemic on medical education and how we must seize the moment to produce a fit-for-purpose health workforce. This workforce must be ready to respond to pandemics and address the social injustice and inequalities COVID-19 has revealed, including their effects on vulnerable populations. In our view, this is a transformational moment for medical education; a disruptor offering opportunities for true reform. Achieving this requires integration of competency-based, place-informed health education with virtual care, informatics and attention to both health system and physician resilience while rethinking the scope and breadth of the health team trained to meet looming challenges.

Learning from the impacts of the pandemic on medical education

There have been many adjustments over the past year, including suspension or restrictions on medical student clerkships and campus-based learning, wholesale moves to remote and online learning, use of the virtual environment for clinical skills and laboratory sessions, online examinations, adaptation of accreditation requirements and sending students out into the community to help. COVID-19 has also highlighted the embedded inequities and fragmentation in our health systems, shedding light on unfair financing, service delivery and education models that systematically exclude the most disadvantaged from health care and education options2,3.

An important topic that has yet to receive much attention is how these adaptations and disruptions in conventional approaches to medical education might actually help drive greater social accountability of health professional schools towards the populations that they serve.

For example, given the COVID-19 experiences, how might we now approach medical program design that educates and trains graduates ‘from, in, with and for’ underserved and rural communities? How might medical education adapt to evidence of service interventions measurably improving community health? How might community priorities become the driver of academic programming rather than academic priorities being the main driver of what is offered to communities? How might the challenges imposed by the COVID pandemic accelerate responsiveness, adaptability and the pace of change? For example, rapid deployment (and uptake) of telemedicine for clinical care (previously thought too difficult) can also facilitate distributed teaching and learning models4. Additionally, growing recognition of the role of community health workers in promoting community health now finds them integrated into the health system and healthcare teams5.

Implications of COVID-19 for ongoing medical education

The United Nations High Level Commission on Health Employment and Economic Growth argued that an increased investment in health workforce must yield better societal outcomes, effectively and efficiently6,7. In medical education, there are many examples of public spending on medical workforce (often in the name of underserved and rural populations) translating instead to urban medical subspecialisation, fragmentation of care, inefficient and ineffective health spending and economic medical migration3. This pandemic caught health systems by surprise. More than 80% of hospitalised COVID-19 patients had underlying conditions easily treatable by primary care teams8. Yet, health systems and traditional medical education are still specialty driven, with insufficient emphasis on primary care or integration of public health into clinical education and basic health systems9,10.

Effective and efficient care demands high quality primary care and social services for:

  • appropriate community-based triage, testing and tracing
  • prevention and treatment of comorbidities in the communities where patients live
  • strong integration with hospital care when needed10,11
  • broadening the scope of medical education to encompass skills in population health and intersectoral bridge-building.

It is no surprise then that key strategic challenges for medical education include:

  • promotion of ‘generalist’ careers among medical graduates12,13
  • achieving a more equitable geographic distribution of medical workforce
  • growth of public health degrees and certificates as medical school options14
  • in-country retention of medical graduates in low- and middle-income country (LMIC) settings.

Promoting the ‘social mission’ of medical schools and other health education institutions is seen as an important way to contribute to better health outcomes3. The development of ‘socially accountable medical education’ and the practical learning among medical schools committed to this agenda are highly relevant in this regard.

THEnet: a community of practice for social accountability in health professional education

The Training for Health Equity Network (THEnet) is a community of practice of 13 medical and health professional schools with a commitment to producing and supporting a health workforce to meet the needs of the communities they serve (Box 1). Located largely in rural and underserved areas of 10 low- and high-income countries, these schools share a focus on:

  • recruiting students from underserved and under-represented populations
  • providing a balanced curriculum with a primary care focus that integrates the psychosocial, biological and clinical sciences
  • delivering the program in large part in the community in underserved areas
  • providing postgraduate training options that address local health workforce needs15.

Box 1:  Health professional schools in the Training for Health Equity Network table image

THEnet is a learning network, where innovations are shared among members and across sectors, but where member schools learn from institutions across the globe and share their innovations in kind. Evaluation to hold ourselves accountable for outcomes is an important part of this work. Our research shows excellent outcomes in terms of intentions to practice and actual practice in rural and underserved areas, practice in generalist disciplines, broadening the health team to include community-based health workers16 and health extension regional officers17, and remaining in country to serve rather than emigrating, for LMICs18. Longer term data from some schools suggest that these intentions translate well into actual practice19,20.

Many of these innovations, used with demonstrated success in THEnet schools, may be of considerable utility to other medical schools trying to adapt their ways of doing things to a post-COVID world, while advancing social good and health equity. Some examples follow from THEnet partner schools of innovations that, as a result of COVID-19, may now have accelerated adoption among mainstream schools (Box 2). 

Box 2:  Examples of prosocial innovations in education from THEnet schools21,22table image

Moving forward: educating future health professionals

To play an optimal role in strengthening societal health and wellbeing, health professional schools must respond and hold themselves accountable for addressing regional health and health system needs. Accreditation of medical schools needs substantial reform with new standards that require schools to prepare physicians to be competent to treat marginalised and vulnerable populations. As leaders in health professional education, we see a role in assisting health systems to respond quickly to emerging crises with pre-emptive disaster planning that includes necessary adjustments to health professional training to ensure that our students and graduates are important drivers of change into the future. 


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5 Nkouaga C, Kaufman A, Alfero C, Medina C. Diffusion of community health workers within Medicaid Managed Care: a strategy to address social determinants of health. Bethesda, MD: Health Affairs Blog, 2017.
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7 World Health Organization, International Labor Organization. 2016. High-Level Commission on Health Employment and Economic Growth. Geneva: World Health Organization, International Labor Organization.
8 Centers for Disease Control and Prevention. Evidence used to update the list of underlying medical conditions that increase a person's risk of severe illness from COVID-19. 2020. Available: web link (Accessed 23 July 2020).
9 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly 2005; 83(3): 457-502. DOI link, PMid:16202000
10 World Health Organization. An unprecedented challenge: Italy's first response to COVID-19. Geneva: World Health Organization, 2020.
11 Art B, Deroo L, De Maeseneer J. Towards unity for health utilising community-oriented primary care in education and practice. Education for Health 2007; 2: 74.
12 Larkins S, Evans R. Greater support for generalism in rural and regional Australia. Australian Family Physician 2014; 43(7): 487-490.
13 Strategic Advisory Council – Welfare, Health and Family. Vision statement: new professionalism in care and support as a task for the future. Brussels: Strategic Advisory Council – Welfare, Health and Family, 2015.
14 Geppert C, Arndell C, Clithero A, Wiese WH, Wiggins CL, Cosgrove EM, et al. Reuniting public health and medicine. American Journal of Preventive Medicine 2011; 41: S2154-S2159. DOI link, PMid:21961667
15 Larkins S, Preston R, Matte MC, Matte IC, Lindemann R, Samson FD. Measuring social accountability in health professional education: development and international pilot testing of an evaluation framework. Medical Teacher 2013; 35(1): 32-45. DOI link, PMid:23102162
16 Page-Reeves J, Kaufman W, Bleecker M, Norris J, McCalmont K, Ianakieva V, et al. Social determinants of health in a clinical setting. Journal of the American Board of Family Medicine 2016; 29(3): 414-418. DOI link, PMid:27170801
17 Kaufman A, Dickinson W, Fagnan L, Duffy D, Parchman M, Rhyne R. The role of health extension in practice transformation and community health improvement: lessons from 5 case studies. Annals of Family Medicine 2019; 17: S67-S72. DOI link, PMid:31405879
18 Larkins S, Johnston K, Hogenbirk J, Willems S, Elsanousi S, Mammen M, et al. Practice intentions at entry to and exit from medical schools aspiring to social accountability: findings from the Training for Health Equity Network Graduate Outcome Study. BMC Medical Education 2018; 18(1): 261. DOI link, PMid:30424760
19 Woolley T, Larkins S, Sen Gupta T. Career choices of the first seven cohorts of JCU MBBS graduates: producing generalists for regional, rural and remote northern Australia. Rural and Remote Health 2019; 19(2): 4438. Available: web link, PMid:30943751
20 Halili S, Cristobal F, Woolley T, Ross SJ, Reeve C, Neusy A-J, et al. Addressing health workforce inequities in the Mindanao regions of the Philippines: tracer study of graduates from a socially-accountable, community-engaged medical school and graduates from a conventional medical school. Medical Teacher 2017; 39(8): 1-7. DOI link, PMid:28580824
21 Larkins S, Michielsen K, Iputo J, Elsanousi S, Mammen S, Graves L, et al. Impact of selection strategies on representation of underserved populations and intention to practise: international findings. Medical Education 2015; 49(1): 60-72. DOI link, PMid:25545574
22 Art B, De Roo L, Willems S, De Maeseneer J. An interdisciplinary community diagnosis experience in an undergraduate medical curriculum: development at Ghent University. Academic Medicine 2008; 83(7): 675-683. DOI link, PMid:18580088

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