Performance of Medical Schools and Students in a Rapid Expansion Era: A Cross-sectional Analysis

Background The rapid expansion of medical schools has been widely adopted as a strategy to address physician shortages and improve access to healthcare. In Brazil, a national policy implemented in 2013 substantially increased medical training capacity, largely through private-sector participation. However, concerns persist regarding whether rapid expansion improved access for students and patients while sustains educational quality. São Paulo is the most populous and economically developed state in Brazil, with structural, regulatory, and market characteristics comparable to those observed in middle- and high-income countries. This offers an informative analytical case to examine the effects of large-scale medical school expansion in a complex health professions education market. Methods This observational, descriptive, cross-sectional study analysed all active undergraduate medical programs registered in the Ministry of Education’s e-MEC system in São Paulo State between 2013 and March 2025. Expansion patterns, geographic distribution, and regional socioeconomic characteristics were assessed using publicly available administrative data. Educational performance was evaluated using official data, the National Student Performance Exam (ENADE 2023) and the Preliminary Course Concept (CPC). Descriptive statistics and non-parametric tests were applied for group comparisons. Multivariate generalized linear models were used to assess associations between institutional characteristics and student performance. Results Between 2013 and 2025, 42 new medical programs were authorized, resulting in a 74.7% increase in available training seats. Expansion was predominantly driven by private institutions, which accounted for 80.5% of newly authorized seats, and was spatially concentrated in regions with higher socioeconomic development and stronger healthcare infrastructure. Regions with lower development indicators experienced little or no expansion. Medical schools with further from their establishment date and public ownership achieved significantly higher student performance scores, whereas newer, predominantly private institutions showed greater variability. Although public institutions demonstrated stronger student performance, they received lower ratings in infrastructure and didactic–pedagogical organization. In multivariate analyses, institutional age and ownership remained independently associated with student performance, while no variables showed significant associations with the overall institutional performance score. Conclusions The expansion of medical education in São Paulo State produced substantial quantitative growth but failed to reduce territorial inequalities. Educational quality was more strongly associated with institutional maturity and public ownership than with expansion alone. As an analytical case reflecting dynamics seen in other regulated health education systems, our example highlights the limits of market-driven expansion and underscores the need for integrated policies that align growth with quality assurance, accreditation, and workforce retention strategies to promote equitable and sustainable healthcare access.