Number of Citations: 4

Submitted: 31 July 2019
Accepted: 6 October 2019
Published online: 1 September, TAPS 2020, 5(3), 5-9
https://doi.org/10.29060/TAPS.2020-5-3/GP2178

Rachmadya Nur Hidayah¹, Richard Fuller² & Trudie E. Roberts³

¹Department of Medical Education and Bioethics, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Indonesia; ²School of Medicine, Faculty of Health and Life Sciences, University of Liverpool, United Kingdom; ³Leeds Institute of Medical Education, Faculty of Medicine and Health, University of Leeds, United Kingdom

Abstract

Southeast Asian region has been experiencing significant challenges to their health care systems, driving some countries establishing policies to ensure the quality of the medical workforce through the introduction of national licensing examinations. This paper examines the experiences of Southeast Asian countries in implementing licensing examinations, highlighting the changes and development of the education policy and its impact on medical education. The lesson learnt from the high-stakes assessment policy offers a new perspective on how medical licensing examinations could represent a potential regional approach for a better health care.

Practice Highlights

• ASEAN countries have been implementing national licensing examinations to ensure the quality of health care education and practice, while at the same time, anticipate the increasing migration of health care professionals in the region.
• The consequences of medical licensing examinations on education varied between countries and regions implementing the policy. The development of National Licensing Examinations in Southeast Asia region has been driving changes in education as its consequences. Looking at the impact, there is a possibility that this policy will lead to greater impact on health care, which may be different than the consequences of similar policy in the Northern America and European context.
• The experience of ASEAN countries such as Indonesia, Thailand, and Lao, offers an insight on how the licensing examination policy drives improvement in medical education through collaboration between stakeholders. This effort should work alongside the strengthening of accreditation system for medical education. The improvement is necessary to support health care policy and produce better quality of medical and health care professionals.

I. BACKGROUND

Healthcare in Southeast Asia faces a major challenge–that of delivering high quality, safe care to one of the most populated areas in the world, alongside rapid regional development. The trend in disease burden is shifting to non-communicable diseases, along with the challenge of globalisation which contributes to the migration of patients and health care professionals. It is known that the migration from low- and middle- income countries, or from developing to developed countries, is more common than the opposite (Tangcharoensathien et al., 2018). The migration of health care workforce has been followed by the international movement in medical education (e.g. offshore medical schools), which have created global-local tensions in medical education. In the interest of ensuring the quality of care and patient safety, the WHO through its Global Code of Practice on the International Recruitment of Health Personnel, recommended the implementation of mandatory national licensing examinations (NLEs) by regulatory bodies have been viewed as supporting this high-stakes education policy, which was in line with the increasing practice of licensing examinations in Southeast Asia countries (Tangcharoensathien et al., 2018).

II. NATIONAL LICENSING EXAMINATIONS: LESSONS FROM NORTH AMERICA AND EUROPE

The policy of using licensing examinations for quality assurance of graduates (and arguably supporting better health care outcomes) has been used in other parts of the world. The United States Medical Licensing Examination (USMLE) and the Medical Council of Canada Qualifying Examination (MCCQE) are the most notable examples. Although firstly established as an effort to reduce variation among practitioners, the USMLE has been developed to an assessment system for international medical graduates as well as home graduates who wish to be licensed in the US or Canada. Both the USMLE and MCCQE went through changes in the administration; from essay and oral examination into a more systematic MCQ and clinical skills assessment in the last two decades. Licensure’s focus shifted into educational outcomes, projecting of continuing medical education and revalidation, the use of technology and psychometrics. NLEs in the Northern America are viewed as effort on ensuring the quality of both home medical graduates and migrating health care professionals.

The impact of NLEs in both countries have been a topic for research in this area. Changes in medical schools’ curricula, especially after the implementation of clinical skills assessment, were reported. Better performance in NLEs have been associated with better preventive and management in primary care; fewer patient complaints; better patient care for international graduates and better performance in postgraduate assessment. However, there were no evidence showing direct impact of NLEs to patients, which raises debate on whether the NLEs ensure patient safety. Despite the debate, the NLEs in both countries have become cornerstones of educational quality assurance system, which also relies on the accreditation system of medical schools and continuing professional development.

European countries have different approaches to the issue of health care professionals’ migration and quality assurance. As European Union (EU) member countries recognise the qualification of health care professionals graduating from other EU countries, there are equal opportunities for them to work within the EU, particularly for medical doctors. Although there are examinations for foreign graduates, the focus is more on language competency rather than medical knowledge and skills. Whilst there are concerns about the diversity of curricula among EU countries, many experts believed that the accreditation systems were sufficient to assure the quality of their graduates (Archer et. al, 2017). Despite this, countries such as Switzerland, Poland, and Germany, have established medical licensing examinations for their home graduates and non-European Economic Area (EEA) countries’ graduates. In 2015, the General Medical Council in the United Kingdom followed this step and plans to start their medical licensing assessment (MLA) (Archer et al., 2017) which the GMC will put into action in 2023. The MLA is designed to be embedded in medical schools’ assessment, which means that there will be consequences in education that could be anticipated in the future.

The two regions might have different approach in quality assuring the graduates and medical practice depending on how the education and healthcare system work in the regions. However, it is worth to notice that the policy, along with accreditation systems, could change the practice of education and possibly the health care system.

III. NATIONAL EXAMINATIONS IN ASEAN: THE POSSIBILITY OF REGIONAL APPROACH FOR BETTER CARE?

Although the approaches taken by the EU countries and ASEAN countries are similar, it is worth noting that the context of patient management policies in both settings are different, as well as their education systems. As they work towards the ASEAN Vision 2020 on Partnership in Dynamic Development, ASEAN countries agreed a number of frameworks to enable the free flow of services for professionals in health care. The mutual recognition arrangements (MRA) for nurses, medical and dental practitioners in ASEAN countries were created in 2006-2009 in response to the partnership. This arrangement required countries to establish regulations for migration of health care professionals. The regulations came in the form of a licensing examination, which have subsequently shaped health care professions education policies in a number of member states.

For these countries, introducing national licensing examinations was not solely about the need to regulate foreign health care professionals, but also to improve the quality of graduates. Most of ASEAN member states are developing countries sharing similar challenges: inadequate numbers of physicians, uneven distribution of health care professionals, and a developing education and health care system (Kittrakulrat, Jongjatuporn, Jurjai, Jarupanich, & Pongpirul, 2014; Sonoda et al., 2017; Tangcharoensathien et al., 2018). The challenges are often followed by the increasing number of medical schools to produce more doctors –as in Indonesia’s case, without a rigid quality assurance system, raising concern of lower quality of graduates. As these countries lacked regulation of health care professionals through existing licensing and re-licensing policies, they started to introduce the NLE as a way of using education and assessment to achieve better health care globally.

Four out of ten ASEAN member countries have implemented NLEs to date: Thailand, Philippines, Indonesia, and Malaysia. Each country has different reasons for introducing the policy. Thailand and Indonesia introduced the NLE for home and international graduates in 2006-2007, to ensure the quality of competent doctors and to improve the quality of their medical schools. In Indonesia, there has been an increasing number of medical schools in the last decade, leading to concerns of differential quality of education delivered which impact on the Government’s policy to improve the quality of health professions education. Philippines and Malaysia, both had NLEs for international graduates only, whose number has been increasing in the recent years. Even though the other countries in the South East Asia region currently do not have NLEs, the topic is being discussed amongst policy makers (Kittrakulrat et al., 2014; Sonoda et al., 2017). Vietnam and Lao are in the process of developing NLEs, and India is considering the NLE as part of their policy in ensuring international graduates are prepared to work in its healthcare system. The increasing trend of health care professions’ migration (Tangcharoensathien et al., 2018) means that the NLE is a relevant issue aligned with the idea of ASEAN Economic Community (AEC), where medical professions can be qualified to practice medicine in another country in this region (Kittrakulrat et al., 2014). For a comparison, other countries in Asia such as Taiwan and South Korea have been establishing medical/ health care professionals licensing examinations, which showed impact on medical education.

Although ASEAN countries have been implementing NLEs to address the influx of international graduates, the fact that the examinations are mostly delivered in local languange makes it complicated for a regional approach of licensing examinations in the era of AEC. Similarly, the difference in culture, economy, education and health care system, also poses another challenge for the free-flow of health care professionals in AEC. Variation of methods and types of licensing examinations exist in countries implementing NLEs; although the knowledge and clinical skills are the most common outcome to be assessed (Price et al., 2018). Even so, the current practice of NLEs might open opportunities for finding common and equal standard for patient care and medical education in ASEAN.

IV. LESSON LEARNT FROM MEDICAL LICENSING EXAMINATIONS IN ASEAN: INVESTING IN HEALTH CARE PROFESSIONALS’ EDUCATION

The development of the NLE in developing countries such as ASEAN members offers a pathway for improving medical and to further extent, health care professionals’ education systems. For these countries, even though the number of overseas qualified doctors may not be significant compared to domestic graduates, the policy was considered an important step towards producing competent health care professionals. It is about how a country moves forward by changing policies, improving education system, and aiming to produce better health care providers.

The policy to improve the quality of health professionals is in line with WHO strategy to invest in transforming the education and training of human resources in health. The transformational strategy emphasised by WHO relies on collaborative work between higher education and the health sectors through establishing national policies to secure the education standard and funding. Therefore, for ASEAN countries implementing the NLE, it represents an investment for health education improvement, and a means to support their health care systems in the future.

Lao’s experience in developing the NLE showed how the country changed its policy and strengthened their education system (Sonoda et al., 2017). In the process of establishing the NLE, Lao needed to strengthen their education system through policies and working with their stakeholders. In Lao’s case, these efforts were considered as significant moves toward better healthcare. The government took note that to produce competent health care professionals, they needed to improve the education system which made them revise educational curricula and assessment practices. The example from Lao’s experience showed that the introduction of NLE drives improvement in health care professions education which is necessary to produce competent professionals (Sonoda et al., 2017). In Thailand, the licensing examination drove changes in undergraduate education (e.g. recognising at-risk students) and postgraduate education. While in Singapore, the national examinations have been introduced in postgraduate studies for ensuring quality assurance (Ruth et al., 2018).

The extent of the NLEs’ roles in bringing health care improvement in ASEAN countries is potentially greater still. In Indonesia, which has the largest population in ASEAN, the NLE for medical graduates was part of government strategies to empower human resources for health and improve the quality of health care professionals. As reported by the Joint Committee on Medical Doctor Competence examination in 2013, the examination was designed to lever the quality of medical education, including medical schools, in the long run. Emergent work from Indonesia (Hidayah, 2018) highlights that the NLEs led to a number of positive consequences for medical education:  improvement in educational practices, improvement of learning resources and facilities, and collaboration between education institutions and health care providers. Since its implementation in 2007, other health care professionals such as dentistry, nursing, and midwifery have been developing, along with the strengthening of accreditation system. The collaboration between stake holders and the culture of Indonesia led to the collective work in scaling up the education. Hidayah’s work (2018) revealed that medical schools have been upgrading their education quality to produce competent graduates. The effort came in the form of increasing collaboration for curriculum and assessment development, expanding clinical placements, and collaboration for faculty development. For example, there have been regional collaboration for assessment practice between medical schools as reported by the National Committee in Indonesia. Especially for new and private schools, this collaboration helps them in leveraging their educational practice. Research highlights that in the context of developing medical education such as Indonesia, the NLE acts as a catalyst to drive improvement, linking the vital role of the regulator (i.e. the government) and major stakeholders (e.g. association of medical schools) (Hidayah, 2018). In the long term, this improvement in the quality of education is expected to bring improvement in health care by ensuring the quality of medical education and medical graduates.

In the broader field of health professions education, national licensing examinations remain a hotly debated policy (Archer et al., 2017). However, the experience of ASEAN countries in implementing NLEs reveals opportunities for a bigger role for this high-stakes assessment in the quality assurance system of health care professionals in order to enhance the quality of health care. In the future, lessons learnt from how an education policy can support developing countries in improving their health care quality, has the potential to enhance the approach to health care problems globally.

Notes on Contributors

Rachmadya Nur Hidayah conducted the research as her PhD project, and its results were used in this article. She conducted literature search, designed the concept of this review and write the manuscript.

Richard Fuller supervised the research project, contributed to the concept design of the manuscript and revised the draft of the manuscript.

Trudie E. Roberts supervised the research project, contributed to the concept design of the manuscript and revised the draft of the manuscript.

Ethical Approval

The authors sincerely thank Rebecca O’Rourke for her helpful feedback for the manuscript.

Acknowledgements

The authors sincerely thank Rebecca O’Rourke for her helpful feedback for the manuscript.

Funding

The work by Hidayah cited in this study was a doctoral study, fully funded by the Indonesia Endowment Fund for Education (LPDP – Lembaga Pengelola Dana Pendidikan), the Ministry of Finance, Republic of Indonesia.

Declaration of Interest

Although the study referred in this manuscript was a doctoral project funded by the government of Indonesia, the authors declare that there is no conflict interest related to the discussion presented in the manuscript.

References

Archer, J., Lynn, N., Coombes, L., Roberts, M., Gale, T., & Regan de Bere, S. (2017). The medical licensing examination debate. Regulation & Governance, 11(3), 315-322. https://doi.org/10.1111/rego.12118

Hidayah, R. N. (2018). Impact of the national medical licensing examination in Indonesia: Perspectives from students, teachers, and medical schools (Doctoral dissertation, University of Leeds). Retrieved from http://etheses.whiterose.ac.uk/20215/

Kittrakulrat, J., Jongjatuporn, W., Jurjai, R., Jarupanich, N., & Pongpirul, K. (2014). The ASEAN economic community and medical qualification. Global Health Action, 7, 24535. https://doi.org/10.3402/gha.v7.24535

Price, T., Lynn, N., Coombes, L., Roberts, M., Gale, T., de Bere, S. R., & Archer, J. (2018). The international landscape of medical licensing examinations: A typology derived from a systematic review. International journal of health policy and management, 7(9), 782. https://doi.org/10.15171/ijhpm.2018.32

Lim, M. C. R., Tsou, Y. K. K., Ong, C. P., Wong, K. W. S., Tan, C. S. G., Soon, S. W. W., … & Cruz, M. S. P. (2018). Family medicine post-graduate examination reforms in Singapore: A value-driven practical and contextual approach. The Asia Pacific Scholar, 3(3), 39-42. https://doi.org/10.29060/TAPS.2018-3-3/SC1057

Sonoda, M., Syhavong, B., Vongsamphanh, C., Phoutsavath, P., Inthapanith, P., Rotem, A., & Fujita, N. (2017). The evolution of the national licensing system of health care professionals: a qualitative descriptive case study in Lao People’s Democratic Republic. Human Resources for Health, 15(51), 1-13. https://doi.org/10.1186/s12960-017-0215-2

Tangcharoensathien, V., Travis, P., Tancarino, A. S., Sawaengdee, K., Chhoedon, Y., Hassan, S., & Pudpong, N. (2018). Managing in-and out-migration of health workforce in selected countries in South East Asia region. International journal of health policy and management, 7(2), 137. https://doi.org/10.15171/ijhpm.2017.49

*Rachmadya Nur Hidayah
Jl.Farmako Sekip Utara,Yogyakarta 55281
Faculty of Medicine, Public Health, and Nursing
Universitas Gadjah Mada, Indonesia
Email: r.nurhidayah@ugm.ac.id