This study showed the effects of accreditation standards of undergraduate medical studies at FMUB by analyzing them through the lenses of NHWA indicators. The findings show that the accreditation mechanism at FMUB, although implemented for the last fifteen years, has the potential to support quality improvement in health workforce education, but not health care and health workforce policy planning. In 2004/2005, the FMUB initiated to a very significant extent of the process of reconciling learning outcomes and expected competencies by aligning all the elements of study programs with the Law on Higher Education and the Principles of the European Higher Education Area. The following year, standards for the accreditation of medical studies were adopted, which stipulate that all regulatory bodies are obliged not to have a conflict of interest and to have gender equality. Updates and revisions of standards in 2013 and 2016, as well as in 2019, have led to different standards focusing on quality education and training, and partly on social responsibility and addressing social determinants.
This study emphasizes the importance of improving the quality of education accreditation standards for socially accountable higher education, for which health workers, civil society and the community must participate in regulatory bodies. Students optionally participate in regulatory making. Alike healthcare managers who also serve as providers for training placement for students during the studies, students take part in FMUB accreditation surveys. While engaging the civic societies can advance academic quality and demonstrate public accountability, no precise article of the national regulations encourages greater collaboration among stakeholders and community and cultures where students after graduation and deployment will typically provide healthcare services.
The issue of community involvement in the accreditation process is also very problematic in the United States and Canada, where accreditation and regulation of higher education have a long history compared to Serbia. For instance, majority of medical schools do not include community service terms and/or descriptive language in their mission statements, and only 8.5% of medical schools incorporate community service and engagement as a primary or major criterion in promotion and tenure guidelines31. They have six major accreditation systems (the Liaison Committee on Medical Education; the Committee on Accreditation of Canadian Medical Schools; the Australian Medical Council; the General Medical Council; the World Federation for Medical Education; and the Conférence Internationale des Doyens et des Facultés de Médecined' Expression Française: International Association of Francophone Deans and Medical Schools) which essentially concentrate on the quality of medical education processes with variable consideration for the potential links between these processes and the development of a more efficient, equitable, and sustainable health system and the short- and long-term consequences of their programs on population health32.
Following the idea that accreditation process can significantly contribute to building competent health workforce and subsequently lead to better healthcare and meet the society’ needs2,3,32, the current accreditation mechanism of medical studies at FMUB must pursue for innovation, effectiveness and accountability through getting a larger input from different categories of interested parties (for instance, health care providers interested in building professional competency; students interested in acquiring the right to access an international medical license and the civic society interested in equitable access to quality services). Social accountability and social determinants and interprofessional education should be taken as priority standards in the future revisions of the regulatory accreditation mechanism. These priorities would signal a culture of continuous quality improvement of medical education is adopted and genuinely embraced in Serbia. A balanced representation of interested parties including policy-makers, education providers, health workforce labor market, students’ groups and the local community could contribute to a primary goal of accreditation, that is to result in positive patient outcomes33.
In our study, the majority of students and of employers agree that for an independent and quality work, a medical graduate would need more practical and organizational skills. Similar was found by other authors34,35. Since more than 70% of students rated the level of quality of education indicators as good, very good or excellent, the main objectives of integrated academic program of medical studies prescribed by the Rulebook on the organization and conduct of integrated academic studies for obtaining the title of doctor of medicine36,37 were met. Given that standards and criteria of accreditation speak of the institution's ability to produce health workers who are ready to respond to the needs of society38, study results added to the understanding of the advancement of the organization, the general conditions, and the quality and content of teaching process and the study program. They showed that establishing clear and well-designed standards in accreditation process yields opportunity, firstly, to measure the impact of accreditation process introduced into to legal framework of Republic of Serbia by the Law in Higher Education30, and secondly, to improve that process by continuous self-evaluation, also proscribed by the Law and other provisions defined by NEAQA26.
This study methods is limited in terms of measuring the impact of accreditation of medical study program on the quality of health care and subjective opinion of the respondents might contribute to over and underestimation of findings. No conclusion can be borne on causal relationship, rather short-term changes in the accreditation process were measured through reactions to the educational experience of graduates and employers39. Since the socio-economic determinants impact on health progress globally and nationally40, the surveys in future should be aiming to cover larger sample of graduates and students with a different socio-economic background.
A true impact of accreditation may well rest in the ability to promote continuous quality improvement within medical education institutions41, trough integration with health and health workforce strategies/plans4,8–10,23,38.
Despite verified slight improvement in quality of medical undergraduate study program at FMUB from 2013 to 2016, other NHWA indicators showed reducing interest in medical studies. Over the ten-year trend there is an overall decline of freshmen enrollment. A significant share of re-enrollments and a success rate of less than 30% both were inducing a prolonged duration of medical studies. These indicators are important to support justification of certain study programs and the required number of students as foreseen by the new regulation42. Given the emigration tendencies and a high unemployment rate of health workers43,44, only with a new national strategy / plan for health care and health workforce, Serbia will be able to adequately regulate the future of higher medical education at five universities. FMUB, as one that has a third of all medical students in the country with about twenty thousand active doctors in the public sector, itself produces about 2.5% of new doctors per year. However, this study findings are also limited due to absence of exact data on applications and exist/drop outs. Future studies should explore these aspects in student’s cohort data.
Study showed that accreditation standards requiring alignment of health workforce education with national health plan and health workforce strategy can assist in coordinating policies on production of human resources for health toward achievement United Nations SDG 3 - health related goals as well as SDG 4 - Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all9. If continuously monitored, validated and recorded into the central database on health workforce (e.g. national health workforce information system) NHWA indicators informs evidence-based policy decisions according to country needs through identifying significant improvements in transformation and scale-up of HWF education and training in support of UHC and increase ability to guide and intersectoral policy dialogue among the relevant ministries that may include those of education, health and finance10.