Global trends in medical education accreditation

There are currently over 3000 medical schools providing education and training to aspiring physicians around the world. The medical education curriculums, experiences offered, available resources, length of study, etc., vary widely depending on regional, political and other contextual factors. This variability in educational models, combined with the rapid increases in the number of medical schools worldwide [1] and increasing international mobility for education and employment [2] necessitate oversight of quality assurance, such as formal accreditation systems, to ensure medical educational institutions function appropriately [3]. For the purpose of this paper, we use the definition of accreditation as described by van Zanten et al. [4], “a process by which a designated authority reviews and evaluates an educational institution using a set of clearly defined criteria and procedures”.

Accreditation systems in medical education aim to assure various stakeholders, including students, educators in postgraduate educational programs, employers, and patients, that graduates are ready to further their training or begin practice. Oversight of the educational content and pedagogical methods is necessary to ensure that the learning needs of the students are met and endeavor to ultimately impact the quality of medical care provided to patients. While there should also be significant consequences for educational institutions that do not meet the standards, an important aim of the accreditation process should be encouraging ongoing institutional improvement and fostering the dissemination of best practices, both regionally and globally.

The development and sustainability of educational quality assurance systems is supported by various international organizations worldwide. The World Health Assembly in its Global Strategy on Human Resources for Health: Workforce 2030, encouraged all countries to have accreditation for medical and other health training programs by 2020 [5]. The World Medical Association also supports quality assurance mechanisms to promote trust in the health workforce [6]. The World Federation for Medical Education (WFME) Recognition Programme aims to provide an independent, transparent and rigorous method of ensuring that accreditation of medical schools worldwide is at an internationally accepted and high standard [7]. As part of the Recognition Programme, WFME evaluates compliance of accrediting agencies with pre-defined criteria [8].

Since 2005, the Foundation for Advancement of International Medical Education and Research (FAIMER®) has been gathering and publishing data on accreditation activities worldwide. Their Directory of Organizations that Recognize/Accredit medical schools (DORA) lists organizations that recognize, authorize, or certify medical schools and/or medical education programs and related data [9]. Summary data from DORA of accreditation activities around the world showed that while over half of all countries with medical schools indicate that there is a national process of accrediting medical education programs, there was considerable variation in scope of authority and level of enforcement [4]. For example, accreditation is managed and implemented by various organizations/agencies around the world, including professional bodies or associations, such as associations of medical schools, statutory bodies such as Medical Councils, or by national accreditation authorities that conduct quality assurance reviews of all higher education, including health professions education [10]. While the creation of a separate medical education accreditation system, in addition to an accreditation system already in place to review an entire university (including the medical school) could be viewed as redundant, authorities that compared health-care discipline specific accreditation systems with general higher education accreditation processes have argued for the importance of specific quality assurance focused on health professions such as medicine [11, 12].

The purpose of this paper is to explore the current state of medical education accreditation around the world and describe the incidence and variability of these accreditation agencies worldwide. By tracking the founding years of accreditation organizations and comparing our data against that found in 2008 [4], we show the growth and change of such academic accreditors over time, as well as updating the data available for future research. This descriptive study explores trends in agency organization and scope according to both World Bank region and income group, and highlights regions that may need focused accreditation development support.

Table 1 presents information on the level of accreditation that is available for undergraduate medical programs or schools in countries with at least one known medical school (n = 186) by World Bank region. Ninety-two (49%) of these countries currently have access to undergraduate accreditation that uses medical-specific standards. This accreditation is provided by 71 accreditation agencies, of which 23 (32%) are currently recognized by WFME.

There is wide variability in the availability of medical-focused accreditation across the regions, ranging from 31% (n = 13 countries) in Sub-Saharan Africa to 100% (n = 2 countries) in North America. Of all types of accreditation agencies for which we were able to determine their government relationship (n = 189 agencies), about half (n = 94) of the organizations are public, 35% (n = 67) are independent, and 15% (n = 28) are private. Of the medical-education-specific accreditation agencies, 42% (n = 30) are public, 37% (n = 26) are independent, and 21% (n = 15) are private.

Table 2 presents information on the level of accreditation available for undergraduate medical programs or schools in countries with medical schools (n = 186 countries) by World Bank economic group. Sixty-four percent (n = 38) of high-income countries have medical-specific accreditation available to their medical schools, compared to only 20% (n = 6) of low-income countries. More than half of low-income countries did not have undergraduate accreditation systems that we could discern.

To examine scope and tenure of the agencies, we examined trends by region. Findings are summarized in Fig. 2, which contrasts the number of medical education accreditation agencies created in each time period and highlights the recent acceleration of agency creation. Four of the nine regions experienced the greatest increase in medical education accreditation agency establishment since the year 2000; however, East Asia and the Pacific saw the greatest growth in the years 1980–1999, while both South Asia and North America developed most of their agencies pre-1980. The Latin America region has the greatest number of medical education accreditation agencies, followed by the Europe & Central Asia region.

Figure 3 shows the age of undergraduate medical education accreditors on a global map. Medical education accreditation is now available in most larger countries, although it exists in only about half of countries with medical schools. Areas that are still under-represented in this type of accreditation include western Africa, southern and eastern Europe, northern South America, and Scandinavia.

Figure 4 shows the type of undergraduate accreditation agency in each country on a global map. Most smaller countries in Europe, South America, and the Pacific only have access to general accreditation, and many countries in Africa do not have medical accreditation available. Detailed information on the agencies scope and trends over time are reported in the next section of the paper.

Quality of education has been a concern since the early twentieth century and is of particular concern in medical education, as graduates of medical schools provide patient care. Medical education accreditation, first developed 60 years ago, has seen significant growth around the world in the last 20 years. While in 1980 there were only eight such accreditors, by the time of this review there were 71. High-income countries began this trend, with 11 high-income countries served by medical education accreditors before 1980. Growth has been fastest in middle-income countries, which have seen 36 countries begin using medical education accreditation in the last 20 years, but slowest in low-income countries where only six countries currently use medical education accreditation standards. Although low-income countries account for 17% (n = 30) of the countries in this study, they had only 6% (n = 7) of the medical education accreditation agencies worldwide.

These data show us that the use of medical education accreditation and standards, although increasing, is not universal. Although most countries have some type of undergraduate accreditation systems in place, the majority of these do not use standards that are specific to medical education. The Sub-Saharan African region, in particular, has a low incidence of medical education accreditation.

In countries where medical education accreditation exists, the scope and organization of the agencies varies considerably. Some international agencies were found to provide accreditation services in more than 10 countries, while others only served one or two additional countries. Latin America has a high number of private accreditation agencies, while the Middle East and North African region has only two each, and South Asia has none. In Sub-Saharan Africa, public accreditation agencies outnumber private and independent agencies by 4:1, in contrast to Europe and Central Asia where independent agencies are twice as common as either public or private organizations. This global variability in legislative formats is likely due to cultural and historical differences and is not associated with the quality or rigor of the accreditor.

Regional cooperation and international agencies seem to be a growing trend. These transnational initiatives support physician migration, mutual degree recognition, and the sharing of academic resources as technology becomes increasingly accessible. The development and recent growth of WFME recognition also indicates the spread of globalization in this area.

Our data demonstrate that medical education quality assurance systems have been increasing and improving worldwide, which should lead to evidence of more highly skilled physicians and in turn, better patient heath. For example, program data at one medical school in Saudi Arabia were analyzed following accreditation, and the authors conclude that there were significant improvements to the administration, curriculum, and educational processes [17]. In Canada, accreditation encourages medical education programs to establish processes likely to be associated with improved quality [18]. In the US, quantitative analyses have demonstrated that for certain populations of international medical graduates, graduating from an accredited medical school is associated with better performance on the United States Medical Licensing Exam (USMLE) [19, 20]. Recently, a study demonstrated that Canadian accreditation review cycles appear correlated with educational processes that are associated with better student outcomes on a national licensing examination [21]. To the extent that performance on licensing examinations is predictive of improved patient health, these studies provide evidence of a relationship between accreditation and the proficiency of graduates of accredited schools.

While this study provides an overview to medical school accreditation practices internationally, it is not without limitations. This project encountered challenges throughout the data collection and review process, such as a reliance on accreditors’ websites that may not have been updated recently or exist at all, limited access to accreditation process data for many agencies, and a pandemic that may have distracted some agencies from responding to our queries. Complex relationships and international agreements, especially those within the Central and South American region, made confirming accreditation activity for some countries difficult to discern. It is likely that agencies are operational in some countries that we did not find documentation of online. Despite our best efforts to obtain accurate data, track agencies through multiple name changes and organizational structures, and classify organizations appropriately, some agencies may have start dates considerably earlier or later than recorded, or be miscategorized, due to confusing terminology and multiple interpretations of terms such as “accreditation”, “independent”, or “autonomous”.

According to a recent review of published research on accreditation in basic medical education, accreditation agencies from high-income countries were featured most often, and most studies had at least one author from the United States or Canada [22]. As the number of accreditation agencies and their specific focus on medical education quality assurance continues to increase globally, more investigations from all regions in the world providing evidence of effectiveness are warranted. In addition, while for this study we combined medical and health profession program accreditation data, future research is needed to determine if these systems are organized and implemented the same way, within and across countries, and the impact of separation by health profession on the effectiveness of quality assurance systems.

These data show us that the use of medical education accreditation and standards, although increasing, is not universal. Although most countries have some type of undergraduate accreditation systems in place, many of these do not use standards that are specific to medical education. Most accreditation systems have only developed in the last 20 years. The summary and trend data described in our study can serve as an important resource for further investigations on the effectiveness of accreditation activities worldwide, especially in areas not frequently highlighted in the literature. Descriptive data, such as type and scope of accreditation agencies and country classification statistics, can serve as a basis for frameworks for identifying and disseminating best practices. Our research also highlights regions and countries that may need focused accreditation development support.