Introducing a National Licensing Examination: the case of Ethiopian Associate Clinician Anesthetists
Authors:   , Asemu Yohannes Molla 
Published: April 2024

Ethiopia drastically increased the anesthesia workforce density by training associate clinician anesthetists (also referred to as anesthetists) as a task-shifting and sharing strategy. However, there were growing concerns about educational quality and patient safety. Accordingly, to ensure quality education and patient safety, the Ministry of Health mandated the anesthetist national licensing examination (NLE), which is relatively costly for low- and middle-income settings. However, empirical evidence is scarce to support or refute the appropriateness and usefulness of NLE-based pass-or-fail decisions. Therefore, this thesis investigates the broader impact of introducing the anesthetist NLE in Ethiopia, a low-income sub-Saharan African country.
Using a pre- and post-evaluation design, chapter Two assesses changes in the quality of anesthetists' education due to integrated program interventions, including an NLE. Chapter Three closely explores the qualitative impact of implementing NLE on the quality of anesthetist education. Chapter Four delves further into the concerns and undesirable consequences of the NLE using a qualitative inquiry. Chapter Five quantifies student academic performance changes following the NLE by retrospectively gathering the academic records of anesthetists who graduated before and after NLE implementation. Chapter Six assesses the relationship between student academic performance and NLE scores and proposes academic performance thresholds that predict failing the NLE. Finally, Chapter Seven investigates the association between anesthetists' NLE scores and the quality of perioperative patient care they deliver.
This thesis found that the anesthetist NLE has prompted anesthesia teaching institutions to improve their teaching-learning, assessment, and program quality improvement practices. Implementing NLE is also associated with a modest improvement in the academic performance of anesthetists. Gender disparities in academic performance disappeared following the NLE; even female students performed better in some measurements. The NLE score exhibits a linear relationship with most academic performance measures and an inverse association with the occurrence of critical incidents (including death), indicating that the exam is appropriate for deciding graduates’ readiness. Besides, based on pass/fail thresholds, the NLE could help training programs improve NLE pass rates. Meanwhile, some concerns and unintended consequences of the exam were identified, demanding more work to enhance the exam’s desirable impacts, fairness, and acceptability. On the other hand, the stagnant or declining academic performance among nurse entrants and recently opened university students warrant further investigation.
Overall, the thesis findings will add to the existing literature and policymakers' understanding of task-sharing strategies and the implementation of an impactful NLE in Ethiopia and beyond. Regulatory authorities should enhance the impact of NLEs by verifying skill acquisition, enforcing consistent pass-or-fail decisions, and ensuring equitable access to exam-related information. Also, they should standardize education by accrediting training programs and mandating continuing professional development (CPD) to renew licenses. On the other hand, education sector stakeholders should focus on enhancing in-school student assessment systems, establishing targeted student support systems, and transforming training models to meet international standards. However, task-sharing and shifting strategies should not be considered quick fixes to specialist shortages; well-delineated roles and mandatory regulatory frameworks are critical. Future research agendas may include the impact of program accreditation and CPD.