Introduction
Social accountability is a central theme in contemporary medical education [1, 2]. While originating in community-based education, social accountability is relevant to academic medical centers as a whole. Historically, institutions of medical education, while focusing on improving the health of the population, have neglected the care of the community in which they are situated. This inequity has been described as a form of colonialism [3].
The most effective path to social accountability in medical education remains unclear.  Should efforts to attain it be imposed in a centralized bureaucratic, top-down approach, or should they arise as an organized grassroots effort led by those most affected by inequities [4]? What strategy is best for measuring social accountability: Formal social/accreditation “audit,” peer review, or something else? Answers may vary if the decision-makers are of a classical liberal, neoliberal, or socialist philosophical bent.  In this paper, we discuss the role of top-down and bottom-up approaches in low- and middle-income countries (LMIC).

Bottom-up
Originally, the social accountability movement, before it was applied to medical education, was a grassroots effort by citizens, often assisted by others with power, such as professional or non-governmental organizations, to increase government responsiveness [5]. Potential impediments to the bottom-up approach include diversion of focus from the original vision by either allies or opponents, partial responses that mute the grass-roots involvement and reduce it to a merely symbolic gesture drained of its populist power, or even hijacking of the effort by a centralized, top-down approach by government or non-governmental actors.  

Top-down
As part of a top-down approach, social accountability has been employed as a measure of quality, incorporated into the accreditation of educational institutions in various national and international systems [6-9]. One example is Canada, where the foundational standard calls on schools to define in specific ways how they demonstrate the actual impact of socially accountable undertakings [9, 10]. Both undergraduate and postgraduate programs, accredited by separate systems [11, 12], are expected to show evidence of social accountability. Accreditation for continuing professional development is also based on the requirement for social relevance and impact. Other systems have variably adopted similar expectations, and there is a currently major global initiative linking social accountability and accreditation [6].
“Social accountability includes the willingness and ability to respond to the needs of society, patients, and health and health-related sectors and to contribute to the national and international development of medicine by fostering competencies in health care, medical education, and medical research. 
“Social accountability is sometimes used synonymously with social responsibility and social responsiveness. In matters outside the control of the profession, it would still demonstrate social accountability through advocacy and by explaining relationships and drawing attention to consequences of the policy” [13].
Organizations, such as the World Federation for Medical Education, offer international accreditation, a top-down strategy that includes requirements for social accountability. While useful resources for improving medical education quality worldwide, these organizations de facto contribute primarily to the transferability of credentials for immigration purposes, often from LMIC to high-income countries. This certainly does not facilitate social accountability to the national populations that invest in the training of their physicians and illustrates a potential hazard of the top-down approach, especially when outsiders derive it. Ironically, the above quotation from the 2015 standards is no longer in the 2024 edition [6]. A characteristic of accreditation systems reflecting a top-down approach is that they reflect an audit approach and quality assurance. However, there is ample evidence at the level of both the individual practitioner and the institution itself that the judicious application of peer review to a process of continuous quality improvement is far more effective in bringing about sustained positive change. The fundamental ethical imperative of social accountability is that the system and its practitioners are perpetually called upon to be devoted to the needs and priorities of those that they serve. Thus, engagement of the grassroots and front line of services is essential, and the linkage of top-down and bottom-up forces must be carefully integrated. Failure to do so can result in the unintended consequences of unhelpful priorities and migrations away from areas of need.

Combining
Anecdotally, for many efforts to bring about change, including implementing social accountability, both approaches are needed: Bottom-up for efficacy, top-down for sustainability. Initiation and continued involvement at the grassroots level ensure relevance to the local society, align priorities with those of the community, and enhance buy-in by those most closely affected.  Including a top-down component facilitates logistical stability, often provides financial support, and engages those with the power to effect change.

Permeating
Social accountability should not be merely added as a separate component of education.  Rather, it must be integrated into every aspect of medical education as part of the institution’s philosophical underpinnings. Otherwise it risks being analogous to putting a bandage on a melanoma: addressing a symptom but not the underlying issue.  It is essential that the social accountability movement, from both the top and the bottom, capitalizes on the altruism that attracts most individuals into the healing professions to integrate it into the educational culture. Social accountability is something we are, not just something we do.
The social accountability of a medical school can be thought of as having a positive impact on the health of the population it serves. Thus, it must engage with the health system of which it is part and be involved in the research required to delineate the priority health needs that must be addressed to achieve this purpose. It must act in the development of policies, priorities, and actions that follow from such assessments. Further, it must direct its educational efforts to provide effective and committed practitioners who can be integrated into the needed service and assess their impact [14]. Excellence, as defined in the International Association for Health Professions Education Social Accountability Awards, makes this requirement explicit as a measure of engagement with all aspects of social and environmental systems [15]. 

Conclusion
To achieve social accountability, it is evident that, regardless of the ambient political system or resource status, both top-down and bottom-up forces must be marshalled to achieve this outcome. 

Ethical Considerations

Compliance with ethical guidelines
There were no ethical considerations to be considered in this research. 

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Conflict of interest
The authors declared no conflicts of interest.

Acknowledgments
Special gratitude to Masoud Khandehroo, who formatted the paper according to the journal guidelines.  






References