Affirmative action, financial support, and medical residency outcomes in Brazil: evidence from a national linked cohort study, 2018-2024

BACKGROUND: Medical education and workforces lack heterogeneity worldwide due to socioeconomic barriers, biased recruitment, and structural inequalities. In Brazil, affirmative action (AA) policies aim to address these disparities through quota-based admissions in public universities and financial aid in private institutions. While these measures may diversify the student pipeline, their influence on medical residency (MR) entry and specialty choice is less clear, with implications for those primary care specialties central to health system performance. This study assessed whether AA students in Brazil are less likely to enter MR programs and whether their specialty selection, particularly Family & Community Medicine, differs from peers. METHODS: We conducted a retrospective cohort study using nationally linked data. Medical graduates were identified from the Higher Education Census (2018–2022) and followed for medical residency outcomes using National Medical Residency Commission records from 2019 to 2024. Exposures were: quota admission in public schools, and; financial support in private schools. Outcomes included entry into a nationally accredited MR program and, among those entering residency, selection of Family & Community Medicine. Logistic regression models estimated adjusted odds ratios (aORs) with 95% confidence intervals, controlling for demographic (sex, race, age, schooling background) and institutional factors (region, ENADE scores, school type, and age). RESULTS: The study included 110,911 medical graduates. Among public school students, 28.1% entered via quotas; in private schools, 44.5% received financial support. Quota students were more likely to come from public secondary schools (95.3% vs. 20.1%) and were more racially diverse than peers, with 49.8% identifying as mixed-race and 12.1% as Black, versus 24.6% and 3.9% among non-quota peers. Residency entry was lower among quota students (52.8% vs. 66.7%; aOR: 0.73, 95% CI: 0.67–0.79), but higher among financial aid recipients (55.0% vs. 50.5%; aOR: 1.23, 95% CI: 1.19–1.27). Specialty distributions were broadly similar, though quota students were more likely to select Family & Community Medicine (15.3% vs. 9.7%; aOR: 1.28, 95% CI: 1.09–1.49). A smaller but significant effect was observed among financial aid recipients (8.2% vs. 6.9%; aOR: 1.09, 95% CI: 1.00–1.18). CONCLUSIONS: Quota policies increased diversity in Brazilian medical schools, especially by expanding the representation of Black and mixed-race students, but were associated with lower MR enrolment, possibly due to financial hardship. Financial aid in private schools facilitated residency entry. Both policies encouraged primary care specialty choice, particularly among quota students. These findings highlight the complementary roles of quotas and financial support in shaping workforce heterogeneity and specialty distribution in Brazil and other LMICs.