Over the past two decades, English has become a key medium of instruction in higher education in non-native English contexts, especially Asian countries. Extant research highlights the rapid expansion of English-medium instruction (EMI) and challenges in policy implementation, revealing tensions between different language policy levels (i.e., macro, meso and micro). Thus, a multilevel analysis is needed to understand these tensions. This review examines factors influencing EMI adoption in China, Japan, Malaysia, and Nepal, focusing on policy implementation by educators and students. Findings show that EMI adoption is driven by English's role as a global lingua franca and the permeation of neoliberal ideologies at the macro policymaking level. Such a macro-level endorsement of monolingual EMI has resulted in micro-level inequalities for students, with resistance manifested through multilingual practices, such as translanguaging, in the classroom. The discrepancies between language policies and practices highlight the necessity of reassessing the adequacy of monolingual EMI policies and the importance of adopting a multilingual policy framework. The article concludes with a critical discussion of the trends observed in these contexts and recommends several policy directions for the future.