Objective The aim of this paper is to provide an overview of the major quality assurance strategies, accreditation and licensure, in health professions education. It explores the nature of these regulatory processes using Brazil and the United States as examples because these large systems are at different ends of the developmental continuum. For each, it describes the tensions that arise, offers a critical synthesis of the evidence and maps out future directions. Results Given wide variability among operating medical schools in curricular design, length of study, resources and facilities for clinical training and supervision, the nature of regulatory bodies varies considerably. Nonetheless, they share tensions related purpose and process including quality assurance versus quality improvement, outcomes versus process and continuous versus episodic evaluations and assessments. Clear evidence of effectiveness, especially for accreditation, is scarce and difficult to obtain, particularly as it relates to health outcomes. Conclusions Regulatory processes need to be built around clear definitions of the goals for each stage of professional development, the current movement towards competency‐based education and the variable durations of medical education. These changes must motivate revisions in the content and process of programmes for accreditation and licensure, complimentary efforts towards quality of care, and stimulate a significant research effort. The authors use Brazil and the US as case studies to provide an overview of procedures and tensions related to accreditation, licensure and certification for quality assurance in health profession education.