Between principle and practice: a qualitative study of perceived relevance and impact of the Ethiopian national medical licensing examination

BACKGROUND: In 2019, Ethiopia introduced the National Medical Licensing Examination (NMLE) to standardize medical competence, enhance accountability in education, and ensure patient safety. The effectiveness of such high-stakes exams is significantly influenced by the perceptions of key stakeholders, including medical students, faculty, and school deans. This study investigates their views on the relevance and impact of the NMLE. METHODS: A qualitative descriptive study was conducted with a stratified sample of public and private medical schools. We conducted eight key informant interviews (KIIs) with deans and eleven focus group discussions (FGDs); five with medical faculty and six with graduating medical students. Interviews and FGDs were audio-recorded, transcribed verbatim, coded, and analysed thematically. Data were coded in MAXQDA24 using pre-identified themes and open coding to include newly identified themes. RESULTS: Three main themes and eighteen subthemes were identified. The NMLE was generally recognized as an important tool for establishing minimum competencies, standardizing medical education, and building public trust, particularly among faculty and deans. However, students expressed concerns about redundancy with other assessments and relying solely on knowledge-based assessments. Faculty and deans acknowledged the exam's role in quality assurance and institutional benchmarking but highlighted design flaws and a lack of practical assessments. While faculty expressed trust in the exam's intent, students expressed scepticism due to perceived imposition and transparency issues. The exam encouraged learning and prompted curricular changes, but also resulted in significant anxiety, stress, and a delayed entry into the workforce. Students felt their institutions provided inadequate support. There is strong consensus among study participants on the need for reform on the exam: adding a practical component, applying a stepwise assessment model, reducing redundancy, and improving transparency. CONCLUSION: While the NMLE is recognised for promoting educational quality, ensuring minimum competence and safeguarding patient safety, it is considered inadequate for fully assessing physician competence and redundant with other assessments. The findings highlight gaps between policy intent and implementation, which require collaborative dialogue among stakeholders to co-create meaningful improvements in the assessment and ensure effective policy implementation.