Learning Governance under Constraint: A Critical Case Study of Medical Education Accreditation in Ghana and its Implications for Global Quality Assurance

Abstract

The governance of medical education accreditation in low- and middle-income countries (LMICs) represents a critical global challenge, balancing the urgent imperative to scale up the physician workforce with the non-negotiable duty to safeguard quality. This qualitative study employs Ghana as a critical case to theorise the dynamics of “Learning Governance”, the integrated rules, processes, and power relations that steer an educational system. Through reflexive thematic analysis of interviews with Deans, Clinical Directors, and Medical Interns, the research maps a governance subsystem under strain. Key findings reveal a foundational yet contested system where the legitimacy derived from standardisation is undermined by a pervasive perception of asymmetric regulation between public and private institutions, a significant deficit in robust assessment mechanisms, and the strategic use of accreditation to enforce social accountability. Compared with Ghana’s experience, Sub-Saharan Africa (SSA) illuminates a central tension: the equity-legitimacy nexus, in which accreditors must be both gatekeepers and growth facilitators. The study identifies an assessment chasm, symptomatic of systemic resource constraints, and highlights how accreditation can actively steer the social contract in LMICs. The contested transition from affiliation to chartering exemplifies the lifecycle of governance tools in evolving systems. We argue that strengthening medical education globally, particularly in LMICs, requires moving beyond compliance checklists to foster governance that is equitable, evidence-based, socially accountable, and adaptively intelligent. Ghana’s case offers transferable lessons on navigating the political economy of quality assurance during rapid expansion.