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The social accountability of doctors: a relationship based framework for understanding emergent community… Green-Thompson, Lionel P; McInerney, Patricia; Woollard, Bob Apr 12, 2017

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RESEARCH ARTICLE Open AccessThe social accountability of doctors:a relationship based framework forunderstanding emergent communityconcepts of caringLionel P. Green-Thompson1*, Patricia McInerney1 and Bob Woollard2AbstractBackground: Social accountability is defined as the responsibility of institutions to respond to the health prioritiesof a community. There is an international movement towards the education of health professionals who areaccountable to communities. There is little evidence of how communities experience or articulate thisaccountability.Methods: In this grounded theory study eight community based focus group discussions were conducted in ruraland urban South Africa to explore community members’ perceptions of the social accountability of doctors. Thediscussions were conducted across one urban and two rural provinces. Group discussions were recorded andtranscribed verbatim.Results: Initial coding was done and three main themes emerged following data analysis: the consultation as aplace of love and respect (participants have an expectation of care yet are often engaged with disregard);relationships of people and systems (participants reflect on their health priorities and the links with the socialdeterminants of health) and Ubuntu as engagement of the community (reflected in their expectation of Ubuntubased relationships as well as part of the education system). These themes were related through a frameworkwhich integrates three levels of relationship: a central community of reciprocal relationships with the doctor-patient relationship as core; a level in which the systems of health and education interact and together with social determinants of healthmediate the insertion of communities into a broader discourse. An ubuntu framing in which the tensions between vulnerability and power interact and reflect rights andresponsibility. The space between these concepts is important for social accountability.Conclusion: Social accountability has been a concept better articulated by academics and centralized agencies.Communities bring a richer dimension to social accountability through their understanding of being human andcaring. This study also creates the connection between ubuntu and social accountability and their mutualtransformative capacity as agents for social justice* Correspondence: Lionel.green-thompson@wits.ac.za1Faculty of Health Sciences, University of the Witwatersrand, PV TobiasHealth Sciences Building, 5 York Road, Parktown, 2193 Johannesburg, SouthAfricaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Green-Thompson et al. BMC Health Services Research  (2017) 17:269 DOI 10.1186/s12913-017-2239-7BackgroundThe World Health Organization (WHO) defined socialaccountability of educational institutions as early as1995 [1]. The definition requires that these institutionsdefine and respond to the community’s health priorities.These priorities should be jointly determined by variousstakeholders including the community. This definition iscomplemented by the World Bank’s view that socialaccountability, through empowerment of communities,ensures they achieve sustainable development [2]. Thisdevelopment is enhanced when citizens have a directengagement in defining health priorities and experienceaccountability from their service providers in the healthcare system, including doctors.Woollard describes a partnership pentagram in whichcommunities, policy makers, health professions andadministrators as well as academic institutions relate to eachother equally in an attempt to build a responsive health caresystem [3]. The four key areas in such a health system wouldbe equity, cost effectiveness, quality and relevance [1].While social accountability has taken an aspirationalperspective within educational institutions, there is acritique that calls for the professions’ acknowledgementof the power they hold in health care [4]. This call high-lights the need for greater critical reflexivity in thediscourse around social accountability [4].There have been many responses to the call for socialaccountability. The placement of medical students incommunity sites for their education has built closerelationships with communities [5–9]. The symbiotic re-lationships which are developed between various stake-holders benefit the community and enhance students’learning [7, 8]. However, in most cases, the relationshipsare not well defined and the voice of communities inunderstanding and defining those relationships has notbeen articulated in the literature.Many communities host medical students for part oftheir curriculum in order to achieve their core competen-cies. The medical curriculum at the University of the Wit-watersrand in Johannesburg, South Africa has committedto four competencies - provision of patient care in pluralhealth and social contexts, developing and delivering ap-propriate care extending beyond the acute presentation ofillness, delivery of effective care enhanced by cultural safetyand social awareness and the competency to deliver pri-mary care in defined geographical communities (Universityof the Witwatersrand, 2003). The university achieves thesecompetencies by rotating students through clinical facilitiesand communities in the central urban Gauteng provinceand the rural provinces of Mpumalanga and North West.This study aimed to give expression to the voicesof these communities through exploration of theirperceptions and understanding of the social account-ability of doctors.MethodsThe study was approved by the University HumanResearch Ethics Committee (Clearance M120695). Forthis study, a community was defined as a residentialsettlement which was served by any of the clinical facil-ities through which students from the university rotatedfor their studies. These communities were located in theNorth West, Mpumalanga and Gauteng provinces ofSouth Africa. These were selected because the time thatstudents spent in these areas ensured the communitieswere aware of the university’s presence in that region.Members of the community were identified through aresearch assistant. The research assistant, who waspresent during the discussions, was employed in each ofthe communities to assist with identifying participantswho were not actively in need of acute care at the timeof the study and who would facilitate reflexivity in thediscussions [10, 11].The group discussions were held in various locationssuch as a participant’s home, a school, a church buildingand a research centre which was not directly associatedwith the health facility at which participants receivedtheir regular health care. These were conducted betweenDecember 2012 and August 2013.A grounded theory approach was employed usingeight community based focus groups. Five focus groupswere held in North West and Mpumalanga (Rural 1–5)followed by the three focus group discussions (Urban 1–3) held in Gauteng. These are provinces in South Africa.There were a total 81 community members who tookpart in the focus group discussions of whom the major-ity (63) were women.Participants received a stipend for travel costs incurredby their participation in these groups and refreshmentswere supplied before and after the focus groupdiscussions.The focus group discussions took 45–60 min each andwere guided by a series of questions with exploration ofthe meaning of each response (See Table 1).The focus group discussions were recorded and tran-scribed verbatim.The first author (LGT) is a male specialist clinician withan appreciation of the role which communities can play inmedical education. This researcher moderated the discus-sions. He is also conversant with some of the vernacularlanguages in these areas and used the research assistantfor basic translation occasionally during the discussions.The second author (PMcI) is a female nurse-midwife witha broad experience of health sciences education. The thirdauthor (BW) is an international authority in social ac-countability. All authors had experience in qualitative re-search while this study formed part of the doctoral studiesof LGT. The data were coded using MAXQDA 11 soft-ware by LGT. PMcI co- coded the data. ConstantGreen-Thompson et al. BMC Health Services Research  (2017) 17:269 Page 2 of 7comparison of the data after each discussion facilitatedthe recognition of themes from the coded transcripts [12–14]. Thematic analysis was performed following each dis-cussion and saturation of data was achieved by the end ofthe eight discussions [12, 15]. Trustworthiness of the datawas ensured through the checking of the transcriptionsand the contemporaneous recording of field notes follow-ing each discussion. The groups could not be reconvenedand so member checking was done through the continu-ous checking within the group discussion and constantcomparison in subsequent focus group discussions.The participants in the first two group discussions(Rural 1 and 2) were unable to understand the meaningof social accountability of doctors (Question 3). As aresult, the researcher (LGT) did not ask this questiondirectly in subsequent discussions but rather exploredthe first two responses in greater detail in order tounderstand the community’s expectation of the doctor.In the earlier discussions, the participants raised theexpectation that the university should play a greater rolein the life of the community. This was explicitlyexplored in all the subsequent discussions. The viewsexpressed led to discussion and consensus within thegroup. Focus groups were conducted so that all partici-pants contributed to the discussions and all contributedfreely to the discussions. Extracts are labelled for thegroup from which each emerged.ResultsCommunity participants were unable to articulate a def-inition of social accountability or suggest how they couldhold doctors accountable. They value the role of thedoctors in their wellbeing but feel powerless to demandany form of accountability. Community experienceswere measured most profoundly by the achievement of ameaningful relationship with the caring doctor.Three major themes emerged from the coded data inwhich the consultation was characterised as a place oflove and respect at the heart of the relationships amongstpeople and systems. Both of these were surrounded bythe notions of Ubuntu as engagement with community.The clinical consultation as a place of love and respectParticipants acknowledged that their encounters withdoctors happened when they were most vulnerable. Theconsultation, as a result, was experienced as both a placeof healing and a place of danger. The participants’ de-scriptions of these encounters evoked the tension be-tween their tenderness and danger of their disease:You see they are supposed to touch with love, becauseinside (the body) it’s very dangerous (Rural 2).The healing which participants expect from their con-sultations was made up of two dimensions: sound rela-tionships which were therapeutic and, only secondarily,the dispensing of appropriate treatments.When I come to the doctor, I have an illness problem. Iwant to get here, sit down and the doctor listens to meand then after listening if the doctor does notunderstand what I’m saying then he can have all theapparatus they use to check me as it is necessary forhim, with care and love (Rural 2).These sound relationships reflect their desire for re-spect and dignity. The notion of love in a consultationwas expressed in the following:Love is when you get a treatment and the doctorexplains it in the way you understand it (Rural 5).The participants anticipate mutual responsibility withinthe consultation where the doctor may collaborate withthem, sharing responsibility for the solution of the pre-senting problem. The participants described the outcomesfrom the consultation as being a product of things thedoctor does, things the patient does and the many thingswhich occupy the relationship space between a patientand their doctor. The doctor’s role and the patient’s roleare mediated through an emotive space – characterised bypain and fear, vulnerability, love and care - which existsbetween them in a consultation. This asymmetrical rela-tionship is imbued with great power differentials.The power accorded to doctors appears to be a functionof patients’ being afraid to confront the doctor (Urban 2)because of the knowledge which the doctor has accumu-lated through university study. The consequence of thisimpotence is that you (the patient) put him (the doctor) ona pedestal (Urban 2). The doctor is placed in a spacewhich is other than that inhabited by the patient.Relationships of people and systemsThe peopleThere was a strong sense that doctors are not part of thecommunities in which they work. Participants describeTable 1 Questions which guided community focus groupdiscussions1. Tell me about your experiences of and with doctors?2. As a member of the community, what do you expect of yourdoctors?3. What, if anything, do you know about the social accountability ofdoctors?4. Do you think that doctors should be accountable to communities?If so, how do you think this should happen?5. What do you think are the major health issues in your community?6. Do you think that doctors need to get involved in issues in thecommunity?Green-Thompson et al. BMC Health Services Research  (2017) 17:269 Page 3 of 7various relationships: between the doctor and the patient,between the patient and the community and between thedoctor and the community. This last relationship is integralto the empowerment for the community. All of these rela-tionships are dynamic and form a reciprocal community ofrelationships amongst all these actors. There is an oppor-tunity for patients, doctors and well members of communi-ties to interact to improve the health of the community assuggested by Fig. 1.Participants had low expectations of the doctors’immersion in their communities but there was anexpectation that doctors should help communities dothings for themselves:Doctors, the one thing they should be doing, is to alertthe community for the community to takeresponsibility to take care of themselves (Rural 5)Community participants listed a series of biomedicalconditions as their health priorities: diabetes mellitus,hypertension, cancer, strokes, HIV and sexually transmit-ted infections, tuberculosis and industrial exposurescausing illness in children. In addition, teenage pregnan-cies and crime and violence associated with substanceabuse form a part of communities’ disease profiles.In addition, they described strong links between these dis-eases and the poor social conditions under which they live:You know poverty causes a lot of things; stress,unhealthy decisions. So most definitely I think povertyplays a big role (Urban 3).Despite this there was a strong sense that communitiescan be developed to take on the responsibility for address-ing the health issues that arise. There was a call for thestrengthening of the role of the doctor in empowering com-munities to work on the social determinants of their health.Multiple dynamic reciprocal relationships impact onthe community’s experience of the health care systemand on their state of health (Fig. 1). The doctor – patientrelationship remains central to the therapeutic process(the conversation I have with the doctors, (it) helps me tobe healed without any treatment - Rural 2). This rela-tionship forms the centre of a broader view of the roleof the doctor as an agent of community empowerment.The systemsParticipants reflected on doctors whom they had en-countered in both private and public health care settingsas being part of complex systems with many parts andmany actors (professionals and support workers)..Many of the groups stated that financial incentivesdominated private practice ensuring greater responsive-ness of doctors in that sector. Communities expressedwillingness to be part of change processes but expectedsimilar responsiveness to their needs within the publicsystem as well. They believed that solutions could onlyemerge from involvement of all levels of the health sys-tem, particularly, the management.Continuity of care was seen as important for account-ability. Participants who saw the same doctor on morethan one occasion in the public sector regarded them-selves as lucky (Urban 2). This was supported by theconcerned comment in one of the discussions:Tomorrow when you come maybe there is anotherdoctor and you don’t know the doctor you see (Urban 3).The reciprocal community of relationships (Fig. 1) is inconstant engagement with a more universal context inwhich power, rights and responsibility interact with eachother. Within this context these relationships encounter: the health care system (they (doctors) don’t useBatho Pele(SeSotho word meaning people first)principles - privacy, confidentiality of the patient(Rural 2)Fig. 1 Community of reciprocal relationshipsFig. 2 Ubuntu as the foundation of empoweredcommunity relationshipsGreen-Thompson et al. BMC Health Services Research  (2017) 17:269 Page 4 of 7 the social determinants of health – poverty (povertycauses a lot of things; stress, unhealthy decisions …we don’t eat healthily – Urban 3) and agency (we asthe community, it’s us who cause all these things –Urban 3). the education system. (I think in as much as theystudy medicine they must study people and thecommunity -Rural 1).Batho Pele embodies a series of values (service excel-lence, consultation with stakeholders, courtesy, access,information, openness and transparency, redress andcost efficiency) which the public service in South Africamade a commitment to uphold. In the health sector thistranslates into the responsibility for the achievement ofhealth for the broader community being shared by allstakeholders – communities, doctors and systems ofhealth and education. The systems which mediate theachievement of health reflect the community’s conceptsof social accountability. Participants reflected on the im-portance of relationships in all these interactions..Ubuntu as engagement of the communityUbuntu, as a manifestation of African humanism, ischaracterised by the relatedness of humanity as sug-gested in the Zulu aphorism: umuntu ngumuntu nga-bantu (a person is a person through other people) [16].Ubuntu’s many facets of respect, dignity, solidarity, com-passion and survival all contribute to the connectionsamongst people as well as their connections to the sys-tems in which they relate [17].Two dimensions of ubuntu were expressed by com-munity participants. These dimensions appear to be acombination of the doctor – community relationshipas well as a humanistic character of the practitioner(… to have humility. To know that you are dealingwith a human being who is not feeling well and youare there (Urban 2).Participants suggest that the university is responsiblefor their graduates’ behaviour:… when you (refers to university) are teaching these doctorsyou need to teach them ubuntu as well, so that they knowwhat to do when they come to communities (Rural 2).In teaching this concept of ubuntu, the community ex-pected that students would emerge from their trainingwith knowledge beyond their biomedical information:I think in as much as they study medicine they muststudy people and the community (Rural 1).Knowing and understanding the community would en-hance the graduates’ capacity for individual and communalhealth care. Participants felt that the university was cur-rently largely unsuccessful in achieving this level of “study(of) community”. In an urban area (Urban 2) where theuniversity appoints the medical staff jointly with the pro-vincial authority, participants did not acknowledge thatthe local hospital represented a joint endeavour betweenthe university and the provincial government. In one ruralcommunity group (Rural 3), the university was seen asvaluing indigenous forms of healing. The involvement oftraditional healers in the undergraduate medicalprogramme facilitated the emergence of these practi-tioners: now we have come out of our rondavels (trad-itional dwellings in South Africa) so that everybody canknow us because of Wits(the university) (Rural 3).This emergence from a traditional space suggests anengagement between the university and its referencepopulation which has already developed in a spirit of co-responsibility. The participants described the participa-tion of doctors in the general life of the community asassisting those communities to take greater responsibil-ity for their health.Ubuntu has been described as both a positive charac-teristic within the individual healing medical encounter(to have humility – Urban 2) as well as an essential partof the education of future doctors (you need to teachthem ubuntu as well – Rural 2). These conceptions ofubuntu are essentially relationship based ideas.The framework of ubuntu is echoed in the partnershippentagram where an ever widening circle of impact isreflected from a local to a national level [3].The humanistic ideal of ubuntu suggests that the pa-tient – doctor relationship is a key element in under-standing both the vulnerability of the attending patientas well as the power held by the practitioner. Interest-ingly, a sense of taking responsibility has emerged fromthe data suggesting an explicit role for community orpatient empowerment in addressing the social determi-nants of health. This important finding offers an oppor-tunity to rethink policies and practices of health systemsthat seem to assume, and even reinforce, a sense of“learned helplessness” of the population in program de-velopment. Properly engaged this empowermentamongst communities and in their relationships withdoctors will shift them towards an attainment of theirright to good health and their shared responsibility formaintaining the state of their health. This Ubuntu ap-proach has been described by participants as the founda-tional concept supporting a positive interaction betweenthe reciprocal relationships and the social determinantsof a community’s health (see Fig. 2).DiscussionThe doctor holds immense power in the clinical consul-tations with individual patients as well as withinGreen-Thompson et al. BMC Health Services Research  (2017) 17:269 Page 5 of 7communities. Despite the asymmetrical nature of this re-lationship, ubuntu within which the patient – doctor rela-tionship may reside is a foundational element for asocially accountable system. This study has articulated thetension which exists within the clinical consultationbetween the patient’s vulnerability and their desire for co-responsibility with the doctor. Malena et al. [2] have de-scribed the interaction between the service provider andthe community as an important accountability relation-ship. Despite the best intentions of transforming environ-ments to achieve this situation, the poor often encounterboth health professionals and front line health managerswhose behaviour may result in injustice for ordinarypeople [18, 19]. It is often the poor who are disadvantagedin the systems which seek their development [2].Ubuntu supports the community of reciprocal rela-tionships as the keystone to socially accountable medicalpractice. Ubuntu frames the local and global experiencein which the social determinants of health and the sys-tems of health care and education interact (Fig. 2).The communities in this study show a good level ofunderstanding of their health priorities. These are simi-lar to national statements on the burden of disease [20].They also highlighted the links between these prioritiesand their social conditions related to poverty and socialbreakdown. The understanding and attitudes of patientsand community members reflects an untapped resourcefor focused change in order to empower communities totake greater responsibility for their health.. While notnecessarily being expressed in terms of “social account-ability”, it is clear that patients and citizens voice an un-derstanding of the required resilience to be active andeffective “pentagram partners” in building a health caresystem based on people’s health priorities—the essenceof social accountability. In addressing health there needsto be a greater focus on a range of social determinantssuch as employment, education and social protection inorder to close the equity divide between wealthy andpoor communities [21]. The study of communities (andperhaps those like them from around the world) is agood place to start.The emergent concepts of relationships (amongstpeople and between systems) from this study are echoedin Worley’s description of the symbiotic relationshipswhich occur in teaching environments which may en-hance social accountability [7, 8]. Hirsh and Worley [22]in conversation with each other place great emphasis onthe role of a different structure of education, based inpart on symbiotic models, as promoting the transforma-tive nature of the graduate which emerges.This study adds to our understanding by adopting theconcept of ubuntu as a richer expression of humanscaring for one another. These intersecting and symbioticrelationships reflect a dimension of ubuntu or Africanhumanism [17]. Mbigi [17] posits that ubuntu in a trans-formative management environment reflects five dimen-sions of human interaction, namely, survival, dignity,respect, compassion and solidarity. Khoza’s view ofubuntu as a dimension of African humanism echoes theneed of the individual for dignity, self-respect and regardfor others [23].The community’s reflections in this study havehighlighted this sense of Ubuntu. They have described itas an essential part of the consultation but, more im-portantly, of the university’s role in relationship with thecommunity.Ubuntu may facilitate the transformation of the trad-itional relationship between the patient (vulnerable) andthe doctor (powerful). It may help to create a spacewhere things often left unspoken in asymmetricalrelationships may gain a voice.ConclusionSocial accountability has emerged in this study as a con-cept which is better understood by academics and cen-tralized agencies. On the other hand, the communitieshave brought a richer understanding of what it means tobe both human and caring. The reflection of these com-munities has located the definition firmly in the contextof relationships. Ritz et al have argued that we will needto acknowledge more clearly that social accountabilitymust be defined by communities as genuine partners insystems transformation [4]. To this end, social account-ability and ubuntu may become the transforming agentsfor social justice as originally intended.AcknowledgementsThe Carnegie-Wits Clinician PhD programme for finanacial support. DiscoveryAcademic Fellowship for funding.FundingSupported by a Carnegie-Wits Clinicain PhD Fellowship and a DiscoveryAcademic Fellowship. The study was completely independent of thesefunders. The work was the original design of the researchers.Availability of data and materialsThe data are transcriptions of focus group discussions. The ethics clearancedoes not allow these data to be available in a public space. However, if thereview process insists that these data be provided, I (LGT) is prepared toobtain specific consent for this to be done.Authors’ contributionsLGT – conceptulised the study, conducted the data collection and analysisand drafted the article. PMcI and RW – provided scholarly input throughoutthe research process. Contributed to the data analysis and interpretation.Participated in the drafting and final editing of the article. Have approvedthis final version of the manuscript. All authors read and approved the finalmanuscript.Competing intereststhe researcher was supported by the Carnegie Foundation. No competinginterests are identified.Consent for publicationNot applicable.Green-Thompson et al. BMC Health Services Research  (2017) 17:269 Page 6 of 7Ethics approval and consent to participateEthical clearance (M120695) has been obtained from the Human ResearchEthics Committee at the University of the Witwatersrand, Johannesburg,South Africa.Each participant completed a consent from for recording and transcriptionof the focus group discussions. Data from focus group discussions wasrecorded and transcribed verbatim. Particpants understood that data couldbe disseminated without identification.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Faculty of Health Sciences, University of the Witwatersrand, PV TobiasHealth Sciences Building, 5 York Road, Parktown, 2193 Johannesburg, SouthAfrica. 2Department of Family Practice, University of British Columbia,Vancouver, Canada.Received: 6 August 2016 Accepted: 7 April 2017References1. Boelen C, Heck JE. Defining and measuring the social accountability ofmedical schools Geneva: WHO; 1995 [Available from: http://whqlibdoc.who.int/hq/1995/WHO_HRH_95.7.pdf. Accessed 10 Apr 2017.2. Malena C, Forster R, Singh J. Social Accountability An introduction to theconcept and emerging practice: World Bank; 2004 [Available from: http://siteresources.worldbank.org/INTPCENG/214578-1116499844371/20524122/310420PAPER0So1ity0SDP0Civic0no1076.pdf . Accessed 10 Apr 2017.3. 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Lancet. 2008;372:1661–9.22. Hirsh D, Worley P. Better learning, better doctors, better community: howtransforming clinical education can help repair society. Med Educ. 2013;47(9):942–9.23. Khoza R. Attuned leadership: Africn Humanism as compass. 1st ed.Johannesburg: Penguin; 2011.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Green-Thompson et al. BMC Health Services Research  (2017) 17:269 Page 7 of 7


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