Affirmative Action, financial support, and medical residency outcomes in Brazil: Evidence from a national linked cohort study.

Background . Medical education and workforces remain homogeneous 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. 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 linking the Higher Education Census and the National Medical Residency Commission. Exposures were quota admission in public schools and financial support in private schools. Outcomes were MR entry and 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 socioeconomically and racially diverse than peers, with 49.8% identifying as mixed-race and 12.1% as Black, compared to 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 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 diversity and specialty distribution in Brazil and other LMICs.