Impact of the national medical licensing examination in Indonesia: perspectives from students, teachers, and medical schools

Introduction The national examination has been increasingly used worldwide for both licensing and certification purposes. In Indonesia, the national licensing examination (NLE) was implemented in 2007 where it serves as a method of quality assurance for both graduates’ competence and medical schools. Indonesia is a developing country which heightens the impact of introducing the NLE. The high cost and resource intensive demands of the NLE are proportionally higher than they would be for Western countries. This adds to the already high stakes nature of the examination for all stakeholders. Consequently, since its implementation, there have been changes in medical education systems and medical schools. However, the research on how the NLE affects medical education is limited. The aim of this study was to understand the consequences of the introduction of the NLE on Indonesian medical education as perceived by three groups of stakeholders: medical schools, teachers, and students. Methods This study was a qualitative study using a modified grounded theory approach to understand the consequences of NLE from multiple stakeholders’ perspectives. A sampling framework was designed to capture important characteristics of Indonesian medical schools based on region, accreditation status, and ownership (public/ private). Interviews were conducted with 18 medical schools’ representatives (vice deans/ programme directors), while focus groups were conducted with teachers and students from 6 medical schools. The interviews and focus groups were audio-recorded and transcribed. Data was analysed in a rigorous method using open coding and thematic analysis to generate cross-cutting themes and concepts. Results This study looked at the intended and unintended consequences of the NLE, which strongly related to the context in Indonesia. Intended consequences were mostly related to the intended outcome of the NLE: achieving a common standard for education, improvement in education practice (including curricula, assessment, and faculty development), improvement learning resources and facilities, which were prominent in new and private schools. Unintended consequences were related to the competition led by the NLE, collaboration, financial impact, and students’ failure. This study revealed cross-cutting themes such as diversity in a rich context of education, the coopetition, and the concept of patient safety in Indonesia. Discussion The current literature on the impact of NLEs were limited to developed countries and Western medical education system. The discourse was mostly based on opinion rather than evidence. This is the first study exploring the impact of the NLE in a developing country and ASEAN network. Some findings on the intended consequences of the NLE confirmed the literature, while some others were a contrast. Indonesia’s unique context as a developing country in Southeast Asia, made it possible for the NLE to create competition leading to collaboration between medical schools and stake holders. This was best explained by the concept of coopetition, which enabled medical schools to overcome challenges, make changes, and improve their quality. This study offers new evidence on how the NLE holds significant role in the improvement of medical education. Conclusion Context matters in the discourse of the NLE. This study demonstrates a novel approach to sampling and analysis of the NLE’s impact. The evaluation of the NLE needs to consider the importance of understanding local factors and consequences. New insights were added to the literature on how the coopetition acts as a key for the impact of the NLE. Moving forward, the future of the NLE is expected to hold an important role in the development of medical education in Indonesia. This study opens opportunities for other area of research, mainly on the impact of the NLE on patient safety, collaboration of stake holders, and students’ failure.