In April 2022 I joined the Centre for Social Accountability at NOSM University in Thunder Bay, Ontario as a part-time Research Associate responsible for research engagement, grant writing, and communications. The aim of the Centre is to improve health and wellness in Northern Ontario through policy leadership and advocacy, research and innovation, and education that better aligns medical training with community needs. The Centre hosts several programs including NORTHH, MERLIN, alongside an Indigenous data sovereignty working group, and it is located on the traditional lands of the Fort William First Nation, signatory to the Robinson Superior Treaty of 1850.
My work with the Centre is on an interdisciplinary team of doctors, research scientists, and scholars in health care education who are interested in socially accountable research and research into social accountability. Working within and beyond the context of medical education and health care, my work with the Centre is focused on developing a distinctive theoretical and critical approach to social accountability.
I’m interested in how violence and conspiratorial thinking bear upon issues of public health, from the complexities of the World Health Organization’s definition of violence to the severe and negative effects that conspiracy theories continue to have on public health. My critical work on Social Accountability is still in its early stages, but for those who are interested, below I have provided a rough draft of a working paper on the topic.
What is Social Accountability?
Critical and Philosophical Considerations
“Subjects only experience disrespect in what they can grasp as violations of the normative claims they have come to know in their socialization as justified implications of established principles of recognition.”Axel Honneth, Disrespect: The Normative Foundations of Critical Theory (Polity, 2007), xii.
Before its conceptualization and application in the contexts of medical education and health care, or its various uses in the context of state governance and civil discourse, the concept of Social Accountability rests upon a series of presuppositions that I want to question in this working paper, beginning with the public values and social bonds that define relationships between societies, communities, and their institutions.
The World Health Organisation provides a helpful and influential definition of Social Accountability, but not before suggesting a precursor-concept called “social responsiveness.” In a WHO working paper, “Towards Unity for Health: Challenges and Opportunities for Partnership in Health Development,” Charles Boelen writes that “social responsiveness is a measure by which a [medical] school responds to societal needs,” as a key part of its service to society (42). Only after defining social responsiveness does Boelen define Social Accountability as the joint identification and prioritisation of “priority health issues and expectations” by both medical schools and the communities they serve. This definition also stands in complex relation to a similar one set forth by the World Bank that focuses on “building accountability that relies on civic engagement, i.e., in which it is ordinary citizens and/or civil society organizations that participate directly or indirectly in exacting accountability.” While the WHO definition is set in the context of health and health care institutions, the World Bank definition is broader and seems to apply to various civil and public institutions.
In the context of health care delivery, the movement toward Social Accountability calls for medical education to become more responsive to society’s health care needs and it advocates for proactive forms of collaboration between public institutions and local communities, provinces, and nations. In one sense, this relationship of accountability and responsibility is predicated on the notion of financial accountability wherein taxpayers’ money is used to fund medical education and care, meaning that because public funds are used, the public should directly benefit from their use and hold institutions to account when they do not serve the public interest.
But the concept of Social Accountability is used in ways that reach beyond the mere exchange of money for services, and even beyond its taxonomic division of values into quality, equity, relevance, and cost-effectiveness, in the domains of education, research, and service (Boelen, 43). In this exploratory paper – where I am testing contextual ideas rather than suggesting final conclusions – I want to contribute to a more expansive definition of Social Accountability that builds upon, critiques, and draws out implicit values within the WHO and World Bank definitions and the broader movement. Specifically, I want to focus on the underlying and implicit priorities, values, and concepts that animate Social Accountability, and eventually to articulate a critical theory of Social Accountability that shows how Social Accountability itself is already a critical theory of society, and then showing how the critical foundations of social accountability can assist the discourse on social accountability in self-reflection and self-critique.
At its most basic level, beneath the notion that medical education and health care ought to be directly accountable to society, are the social bonds that bind together the different domains and sectors of our societies. The very expectation that institutions should serve society is based upon an underlying social bond between the people who make up a population and the institutions that are tasked with serving the public. Without the presence of social bonds between people, and between people and institutions, the concept of Social Accountability loses both its meaning and efficacy. But more important than the fact that there is a social bond that binds society to its institutions are the characteristics of those bonds, which I suggest are (1) inherently normative, and (2) best defined by public trust.
The concept of Social Accountability is inherently normative, meaning that it refers to and asserts how things ought to be rather than merely how things are. Although it may appeal to descriptions, facts, and research data to support its aims, at a fundamental level, Social Accountability responds to an absence of or lack in accountability, and actively asserts an account of how society ought to function. Social Accountability is not scientific if science refers solely to research into facts and quantitatively verifiable states of affairs. Rather, Social Accountability bridges the gap between descriptive scientific research and the normative domains of social theory in the social sciences and humanities in ways that call for interdisciplinary and multidisciplinary inquiry.
In my research I am particularly concerned with the complex relationships between normativity (how things ought to be) and description (how things are), and the place of power amidst the two. Social Accountability is an inherently normative movement within certain spheres of medical education and civil discourse that asserts the importance of the process by which societies (especially those who represent particular communities) hold institutions to account. However, trouble arises when the implicit values of Social Accountability are made universal, for not all nation states are governed under the assumption that institutions should be accountable to society, and even in many nations where this aspiration is present there may be little public trust in the idea that institutions could ever really become socially accountable.
This is why public trust is a constituent part of Social Accountability. Without some degree of shared or mutual trust there is no coherent way to conceptualize the social bonds that bind people together, and without the presence of social bonds, the idea of Social Accountability loses its meaning and coherence – for how could one be accountable to another without feeling bound to them by some obligation or social connection? Put differently, without some form of trust that binds together institutions and society there is no reason to expect that public institutions will serve the public itself, and without that expectation no act of holding to account can occur.
So what is the nature of this kind of public trust that defines the social bonds between people and their institutions? The word “trust” bears an historical and figural relationship with the Latin term credere, from which the English language also receives words for legitimacy like “credibility,” and financialized terms like “credit,” which further inform religious and secular forms of belief. To trust a person or institution requires the formation and maintenance of a bond of trust, and in some ways credibility is stored and communicated in a way somewhat comparable to credit. Just as money is an abstract representation of the trust that people have in the idea that debts will be repaid and labor-value will be reliably held and transferred, the social bonds of trust between society and its institutions also rest upon a confluence of economic value and human values.
Conceived of in this way, Social Accountability is not a neutral idea that arises naturally even within pluralistic western democracies. It is an idea and practice that extends from public values that rest on a distinction between what a good society is and is not. Social Accountability is an inherently normative concept that rests upon a specific vision of how society and its public institutions ought to be (rather than merely how things are), and no robust concept of Social Accountability is possible without first confronting the normativity of the concept and the fact that it rests upon values that must be asserted, argued for, and defended in response to competing ways of conceptualising social institutions – for example, privatised healthcare wherein the social bonds between society and health care institutions are reduced to relations of financial exchange, and high quality care is restricted to the wealthy elite.
When conceptualising Social Accountability as something that rests upon a social bond of public trust, several major tensions and contradictions arise. There is a contradiction, for example, in the idea that social bonds of trust are analogous to financial forms of credit, money, and debt. As mentioned above, one vision of Social Accountability reduces the social bonds of trust required for accountability to a financial relationship wherein the bonds between society, health education, and health care are subjected to economy. This way of thinking about Social Accountability may at first seem to be reliable because economic relationships often promise to provide safety, security, and certainty. However, many critical voices from within the humanities and social sciences have warned and continue to warn that the reduction of social, political, and human relationships to economic, financial, and data-driven forms of measurement carries an immense cost – and this is especially the case in the discourse on neoliberalism.
Quantifying the Social
There is a further tension between the prioritisation of data and metrics, and the social bonds that define Social Accountability. On one hand data is composed of neutral counters, quantities, and numbers, which lack qualities and human characteristics. On the other hand is the act of providing care and the social bonds of trust that motivate and arise from human connections, vulnerabilities, and dependencies. Medical education and medical care rely upon both quantitative measures and metrics, and qualitative resources and forms of judgement in order to provide care and respond to illness and disease. On one hand, medicine would lose its effectiveness in the absence of quantitative, empirical, and data-driven research. On the other hand – perhaps more importantly in the present care crisis – medical care ceases to be a form of care when data and metrics are prioritised over human relationships and attention to the social determinants of health.
The fundamental tension between the scientific tools required to provide high quality health care and the social values that define the act of caring itself is one of the key tensions within Social Accountability as well. On one hand, a socially accountable medical system requires the use of data and metrics in order to make good on its promise to be responsive to society’s healthcare needs and priorities. Without reliable evidence of the effectiveness of their actions and interventions institutions cannot be accountable to the society they serve. On the other hand, socially accountable health care and education is fundamentally a social pursuit, defined by human relationships that scale up from local communities and groups, to societies and nations.
The concept of Social Accountability both rests upon and mediates between the aforementioned tensions, and it requires a more robust paradigm than any one scholarly discipline or discourse can provide. This is why interdisciplinary and multidisciplinary research and inquiry are essential, especially between the sciences, social sciences, and humanities. Rather than conceiving of Social Accountability as a principle that can be explained or achieved through one disciplinary framework the pursuit of Social Accountability needs insights that arise from interdisciplinary connections across different and often conflicting methodologies.