Abstract

This study assesses the effectiveness of policies to expand access to higher education in reducing inequities in the profile of graduates from medical courses in Brazil. This work consists of a cross-sectional study using data from the 2018 Higher Education Census. Analyses were carried out to identify the association between being a beneficiary of the Quota Law, the University for All Program, or the Student Financing Fund and three markers: born in a small-sized municipality, being non-white, or having attended high school in a public school. Analyses were performed using Pearson’s chi-square test, and multivariate analysis was conducted using Poisson regression. A significant association was found between being a beneficiary of these policies and being a non-white graduate, who was born in a small town and who had studied in a public high school. All policies presented adjusted Prevalence Ratio (PR), which demonstrated an association with statistical significance. The Quota Law was the most effective policy, with RP=1.92 for non-white graduates, RP=6.66 for having studied in a public high school, and RP=1.08 for being born in a small town. Despite these results, these groups remain underrepresented in medical courses and in the workforce.

Key words:
Workforce; Medical Education; Public Policy; Socioeconomic factors; Social Segregation

Introduction

Access to medical schools is strongly influenced by socioeconomic and cultural factors, which determine the characteristics of the medical workforce¹1 Mathers J, Sitch A, Marsh JL, Parry J. Widening access to medical education for under-represented socioeconomic groups: population based cross sectional analysis of UK data, 2002-6. BMJ 2011; 342:d918.. Studies have demonstrated that, even in developed countries, such as the United Kingdom¹1 Mathers J, Sitch A, Marsh JL, Parry J. Widening access to medical education for under-represented socioeconomic groups: population based cross sectional analysis of UK data, 2002-6. BMJ 2011; 342:d918.^,22 Kumwenda B, Cleland J, Greatrix R, MacKenzie RK, Prescott G. Are efforts to attract graduate applicants to UK medical schools effective in increasing the participation of under-represented socioeconomic groups? A national cohort study. BMJ Open 2018; 8(2):e018946., the United States³3 Carrasquillo O, Lee-Rey ET. Diversifying the medical classroom: is more evidence needed? JAMA 2008; 300(10):1203-1205., and Canada⁴4 Young ME, Razack S, Hanson MD, Slade S, Varpio L, Dore KL, McKnight D. Calling for a broader conceptualization of diversity: surface and deep diversity in four Canadian medical schools. Acad Med 2012; 87(11):1501-1510., graduates who are from minority ethnic groups or from disadvantaged socioeconomic classes are underrepresented in medical schools.

Brazil is one of the most unequal countries in the world. In 2019, the Gini index for per capita home income was 0.543⁵5 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2020.. In the same year, half the Brazilian population earned only 15.6% of the nation’s income, while the richest 10% concentrated 42.9% of the entire country’s income⁵5 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2020.. The average per capita home income of the black population was approximately half of what was earned by the white population, which demonstrates historical racial and structural inequalities in the Brazilian population⁵5 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2020..

In the field of health, inequalities can be seen in the underprivileged population’s limited access to health services⁶6 Szwarcwald CL, Souza-Júnior PR, Damacena GN. Socioeconomic inequalities in the use of outpatient services in Brazil according to health care need: evidence from the World Health Survey. BMC Health Serv Res 2010; 10:217.^,77 Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. Hum Resour Health 2021; 19(1):33., as well as in a poorer ratio of doctors by population in poorer towns⁷7 Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. Hum Resour Health 2021; 19(1):33.. These differences in accessibility to health services contribute to higher rates of morbidity and mortality in the black⁸8 Baqui P, Bica I, Marra V, Ercole A, van der Schaar M. Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study. Lancet Glob Health 2020; 8(8):e1018-e1026.

9 Leal MDC, Gama SGND, Pereira APE, Pacheco VE, Carmo CND, Santos RV. The color of pain: racial iniquities in prenatal care and childbirth in Brazil. Cad Saude Publica 2017; 33(Supl. 1):e00078816.

10 Ribeiro KB, Ribeiro AF, Veras MASM, Castro MC. Social inequalities and COVID-19 mortality in the city of São Paulo, Brazil. Int J Epidemiol 2021; 50(3):732-742.^-1111 Hone T, Rasella D, Barreto ML, Majeed A, Millett C. Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis. PLoS Med 2017; 14(5):e1002306. and poorest populations¹²12 Mallinson PAC, Luhar S, Williamson E, Barreto ML, Kinra S. Socioeconomic position and cardiovascular mortality in 63 million adults from Brazil. Heart 2021; 107(10):822-827., as became evident during the COVID-19 epidemic⁸8 Baqui P, Bica I, Marra V, Ercole A, van der Schaar M. Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study. Lancet Glob Health 2020; 8(8):e1018-e1026.^,1010 Ribeiro KB, Ribeiro AF, Veras MASM, Castro MC. Social inequalities and COVID-19 mortality in the city of São Paulo, Brazil. Int J Epidemiol 2021; 50(3):732-742.^,1313 Figueiredo AM, Figueiredo DC, Gomes LB, Massuda A, Gil-García E, Vianna RP, Daponte A. Social determinants of health and COVID-19 infection in Brazil: an analysis of the pandemic. Rev Bras Enferm 2020; 73(Supl. 2):e20200673.^,1414 Rocha R, Atun R, Massuda A, Rache B, Spinola P, Nunes L, Lago M, Castro MC. Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: a comprehensive analysis. Lancet Glob Health 2021; 9(6):E782-E792..

Inequalities are also present in the access to higher education¹⁵15 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2018.^,1616 Ristoff D. Democratização do campus Impacto dos programas de inclusão sobre o Perfil da graduação. Cad GEA 2016; 9:1-68.. Students who attend private high schools have twice as many chances to be accepted to college, in comparison to students from public schools¹⁵15 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2018.. The percentage of white students who finished high school and entered college was 51.5%, in comparison to 33.4% of black students¹⁵15 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2018..

The impact of the Brazilian socioeconomic disparities in education was even higher in terms of access to medical schools. A nationwide study based on data from the ENADE 2004 socioeconomic questionnaire found that 67% of the students in the last year of medical school were from families with a family income above 10 minimum wage salaries, 79.4% were white, and only 9% graduated from public high schools¹⁶16 Ristoff D. Democratização do campus Impacto dos programas de inclusão sobre o Perfil da graduação. Cad GEA 2016; 9:1-68.. Data from a 2014-2015 survey identified that 77.20% of the graduates from medical schools were white¹⁷17 Scheffer M. Demografia Médica no Brasil 2018 [Internet]. São Paulo: FMUSP, CFM, Cremesp; 2018 [acessado 2020 nov 20]. Disponível em: http://jornal.usp.br/wp-content/uploads/DemografiaMedica2018.pdf..

The literature describes some initiatives for expanding the access to medical schools to less privileged groups, such as the creation of admission programs, the priority selection of students from poorer areas, student loans, and scholarships for socially vulnerable segments of the population¹1 Mathers J, Sitch A, Marsh JL, Parry J. Widening access to medical education for under-represented socioeconomic groups: population based cross sectional analysis of UK data, 2002-6. BMJ 2011; 342:d918.^,22 Kumwenda B, Cleland J, Greatrix R, MacKenzie RK, Prescott G. Are efforts to attract graduate applicants to UK medical schools effective in increasing the participation of under-represented socioeconomic groups? A national cohort study. BMJ Open 2018; 8(2):e018946.^,1818 Spencer A, Young T, Williams S, Yan D, Horsfall S. Survey on Aboriginal issues within Canadian medical programmes. Med Educ 2005; 39(11):1101-1109.

19 Fielding S, Tiffin PA, Greatrix R, Lee AJ, Patterson F, Nicholson S, Cleland J. Do changing medical admissions practices in the UK impact on who is admitted? An interrupted time series analysis. BMJ Open 2018; 8(10):e023274.

20 Lupton K, Vercammen-Grandjean C, Forkin J, Wilson E, Grumbach K. Specialty choice and practice location of physician alumni of University of California premedical postbaccalaureate programs. Acad Med 2012; 87(1):115-120.^-2121 Girotti JA, Park YS, Tekian A. Ensuring a fair and equitable selection of students to serve society's health care needs. Med Educ 2015; 49(1):84-92.. These actions have two main objectives: 1) to expand the access of students from poorer classes to medical schools³3 Carrasquillo O, Lee-Rey ET. Diversifying the medical classroom: is more evidence needed? JAMA 2008; 300(10):1203-1205.^,1919 Fielding S, Tiffin PA, Greatrix R, Lee AJ, Patterson F, Nicholson S, Cleland J. Do changing medical admissions practices in the UK impact on who is admitted? An interrupted time series analysis. BMJ Open 2018; 8(10):e023274.^,2222 Mensah MO, Sommers BD. The Policy Argument for Healthcare Workforce Diversity. J Gen Intern Med 2016; 31(11):1369-1372. and 2) to expand the access and the quality of care provided to minority group populations or those who live in vulnerable areas³3 Carrasquillo O, Lee-Rey ET. Diversifying the medical classroom: is more evidence needed? JAMA 2008; 300(10):1203-1205.^,1919 Fielding S, Tiffin PA, Greatrix R, Lee AJ, Patterson F, Nicholson S, Cleland J. Do changing medical admissions practices in the UK impact on who is admitted? An interrupted time series analysis. BMJ Open 2018; 8(10):e023274.^,2222 Mensah MO, Sommers BD. The Policy Argument for Healthcare Workforce Diversity. J Gen Intern Med 2016; 31(11):1369-1372.^,2323 Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl AcadSci USA 2020; 117(35):21194-21200.. The second objective is based on the findings from studies which indicate that doctors from minority groups are more likely to work in areas where medical professionals are scarce, thus reducing inequalities in access to health care³3 Carrasquillo O, Lee-Rey ET. Diversifying the medical classroom: is more evidence needed? JAMA 2008; 300(10):1203-1205.^,1919 Fielding S, Tiffin PA, Greatrix R, Lee AJ, Patterson F, Nicholson S, Cleland J. Do changing medical admissions practices in the UK impact on who is admitted? An interrupted time series analysis. BMJ Open 2018; 8(10):e023274.^,2222 Mensah MO, Sommers BD. The Policy Argument for Healthcare Workforce Diversity. J Gen Intern Med 2016; 31(11):1369-1372.^,2323 Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl AcadSci USA 2020; 117(35):21194-21200..

Furthermore, studies suggest that the ethnic-racial concordance between doctor and patient results in better communication, more trust, and patient satisfaction³3 Carrasquillo O, Lee-Rey ET. Diversifying the medical classroom: is more evidence needed? JAMA 2008; 300(10):1203-1205.^,2222 Mensah MO, Sommers BD. The Policy Argument for Healthcare Workforce Diversity. J Gen Intern Med 2016; 31(11):1369-1372.. A recent study conducted in the United States demonstrated that mortality among newborn black children was lower when they were cared for by black doctors²³23 Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl AcadSci USA 2020; 117(35):21194-21200.. Another American study showed that students from schools with a more ethnically diverse students claim that they are better prepared to work in areas with racial minorities or with a poorer population²⁴24 Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA 2008; 300(10):1135-1145..

Since 2003, several programs have been implanted to create more availability and reduce the inequalities in access to higher education in Brazil¹⁶16 Ristoff D. Democratização do campus Impacto dos programas de inclusão sobre o Perfil da graduação. Cad GEA 2016; 9:1-68.. There has been an increase in the number of available places at federal universities, guaranteed by the Program to Support the Plan for Restructuring and Expansion of Federal Universities (REUNI, in Portuguese), and financing policies to improve access of students to private universities¹⁶16 Ristoff D. Democratização do campus Impacto dos programas de inclusão sobre o Perfil da graduação. Cad GEA 2016; 9:1-68.. Among those initiatives, we can highlight the University for All Program (PROUNI, in Portuguese - 2005) which offers scholarships in private universities for students from low income families, and the Student Financing Fund (FIES, in Portuguese - 2001/2010), which provided loans for financing the cost of college education in private universities¹⁶16 Ristoff D. Democratização do campus Impacto dos programas de inclusão sobre o Perfil da graduação. Cad GEA 2016; 9:1-68..

The number of places available in medical schools in Brazil has expanded exponentially in recent years, mostly due to the opening of new private universities⁷7 Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. Hum Resour Health 2021; 19(1):33.. In 2018, there were 35,755 places in medical schools, 25,173 (74.4%) of which were in private schools⁷7 Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. Hum Resour Health 2021; 19(1):33._. At the same time, there was the gradual implementation of affirmative actions (quotas for races and social groups) in public universities, intensified after the creation of Law 12,711/2012²⁵25 Brasil. Lei nº 12.711, de 29 de agosto de 2012. Lei de Cotas: dispõe sobre o ingresso nas universidades federais e nas instituições federais de ensino técnico de nível médio. Diário Oficial da União; 2012., which defined that within four years (2016), 50% of the places available in federal universities should be offered to public high school graduates, additionally considering the criteria of low family income and race/color¹⁶16 Ristoff D. Democratização do campus Impacto dos programas de inclusão sobre o Perfil da graduação. Cad GEA 2016; 9:1-68.^,2525 Brasil. Lei nº 12.711, de 29 de agosto de 2012. Lei de Cotas: dispõe sobre o ingresso nas universidades federais e nas instituições federais de ensino técnico de nível médio. Diário Oficial da União; 2012.. All of these policies are based on criteria that prioritize the access to medical schools for underprivileged individuals; however, only part of the medical school graduates are benefited by these policies.

Evaluating public policies is something relevant, it generates knowledge to allow for better decisions by public agents. It also subsidizes the public debate by society and increases the efficiency of government actions²⁶26 HM Treasury. Magenta Book Central Government guidance on evaluation [Internet]. 2020 [cited 2022 fev 10]. Available from: https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/879438/HMT_Magenta_Book.pdf.
https://assets.publishing.service.gov.uk... . The process of evaluating public policies may focus on different aspects, such as: the analysis of the policies’ design, the implementation process, and the results achieved²⁶26 HM Treasury. Magenta Book Central Government guidance on evaluation [Internet]. 2020 [cited 2022 fev 10]. Available from: https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/879438/HMT_Magenta_Book.pdf.
https://assets.publishing.service.gov.uk... . In this perspective, the current study evaluated the effects of the expansion policies of access to higher education on the profile of the graduates from medical schools in Brazil, aiming to evaluate its impact on the reduction of social and racial inequalities in the makeup of the medical profession.

Methodology

This is a cross-sectional study that analyses data of graduates from Medical courses, available in the databank of the Higher Education Survey by the National Institute of Educational Studies and Research (INEP, in Portuguese)²⁷27 Brasil. Ministério da Educação (MEC). Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira (INEP). Censo da Educação Superior 2018 [Internet]. [acessado 2020 jul 10]. Disponível em: http://inep.gov.br/microdados.
http://inep.gov.br/microdados... . Data from the 2018 graduates were analyzed, since this was the first graduating class after the implementation of the quota law²⁵25 Brasil. Lei nº 12.711, de 29 de agosto de 2012. Lei de Cotas: dispõe sobre o ingresso nas universidades federais e nas instituições federais de ensino técnico de nível médio. Diário Oficial da União; 2012.. The data was extracted using the dplyr package of the R-3.6.1.

The following variables concerning the receiving of loans from FIES, receiving of scholarships from PROUNI (partial or full), admission in college through the system of quotas, administrative category of the medical school where the students graduated from (public or private), sex, and age of the graduates at the conclusion of the course (above or below the average) were analyzed as explanatory variables. The associations between these variables and the characteristics of the graduates were also analyzed: being from a town with less than 20,000 inhabitants in 2010, non-white race/color, and having concluded public high school. These variables were used as proxies to identify changes in the profile of the graduates which could be considered a reduction in social and racial inequalities.

The race/color variable was used to evaluate the increase in racial and ethnic diversity in medical schools, categorized as “white” or “non-white” (black, brown, yellow, or indigenous). Having completed public high school was a marker of economic condition, and the town of origin was a variable used to identify the changes in access to education by students from small towns, which are the locations with a greater scarcity of doctors in the country²⁸28 Girardi SN, Stralen AC, Cella JN, Wan Der Maas L, Carvalho CL, Faria Ede O. Impact of the Mais Médicos (More Doctors) Program in reducing physician shortage in Brazilian Primary Healthcare. Cien Saude Colet 2016; 21(9):2675-2684..

A descriptive analysis was conducted considering the entire database categorized by the administrative category of the higher education institution from which the individuals graduated. Next, bivariate analyses were conducted using the Pearson chi-square test for each of the three variables defined as proxies of reduction of inequality in access to medical schools. For each analysis, the dependent variable was categorized in a dichotomous manner, excluding the graduates with missing data. Analyses were also conducted to compare the presence of differences in the percentage of missing data in each analysis, seeking to identify losses which could not be considered random. All the explanatory variables were considered for the multivariate Poison regression analysis, with a robust estimation for better adjustment in the case of events with great prevalence. The objective of this evaluation was to check the effect, regardless of each of the measures applied to expand access to higher education, on the independent variables, calculating both the Prevalence Ratio (PR) and its respective 95% confidence intervals (95%CI). The statistical analyses were performed using the SPSS package (IBM SPSS Statistics for Windows V.20).

Results

The profile of the graduates (Table 1) indicates a predominance of the female sex, age equal or below 26, born in towns with more than 20,000 inhabitants, and predominantly white. The percentage of female graduates and of individuals over 27 years of age was higher in the private schools. White students made up71.25% of the graduates from medical schools in Brazil, and the percentage of graduates from private medical schools (75.51%) was higher than the percentage found for public schools (64.04%). There was a higher percentage of students who graduated from public high schools among the graduates from public medical school (27.78%).

FIES was the program with the most beneficiaries, used by 30.57% of the graduates, benefiting almost half of the students who went to private medical colleges. The percentage was only 1.31% of the graduates from public high schools, almost all of whom were connected to municipal institutions. Those institutions, although linked to the government, require the payment of monthly fees from the students. Most of the graduates who made use of FIES were people who referred to themselves as white (72.01%).

The PROUNI beneficiaries (partially and fully) were only 5.49% of the graduates from private schools, a much lower percentage than that found for FIES beneficiaries. The majority of the graduates who used the PROUNI were white (53.79%).

Among the graduates, 5.94% were admitted through the quota system, 98.34% of whom studied in public colleges. The percentages of graduates admitted through the quota system were 16.77% for state schools and 15.95% for federal schools. It is important to highlight that not a single graduate from a public municipal school benefited from affirmative action policies. The students admitted to colleges through the quota system were mostly “non-white” (64.25%).

The number of graduates, included in the analyses conducted to evaluate the impact of the policies, varied due to the amount of missing data. The losses were 20.2% for analyses related to race/color, 19.2% for analyses related to the graduates’ place of origin, and 3.9% related to the kind of high school from which the students graduated. The detailed analysis of losses is available in the Table 2.

The analysis of the distribution of graduates by race/color demonstrates that the percentage of “non-white” graduates is higher among men, and among the graduates over 26 years of age. The percentage of “non-white” graduates was higher among the graduates from public universities, among students admitted through the quota system, and among participants of PROUNI. The same pattern did not occur among beneficiaries of FIES (Table 3).

A little less than one fourth of the medical school graduates (24.9%) concluded high school in a public school (Table 4). The percentage of graduates who concluded public high school was significantly higher among the male graduates, among the older students, among the beneficiaries of all the measures applied to improve access to universities, and among the graduates from public medical schools.

There was a higher percentage of graduates among individuals from towns with less than 20,000 inhabitants, among the graduates over 26 years of age and among the beneficiaries of FIES, PROUNI, and the quota system (Table 5).

The multivariate analysis demonstrates that the quota system was the policy which most influenced access to medical schools for “non-white” students (PR=1.92; 95%CI=1.76-2.10; p<0.01), to students who went to public High Schools (PR=6.66; 95%CI=5.68-7.80; p<0.01) and to the ones who were from towns with less than 20,000 inhabitants (PR=1.08; 95%CI=1.05-1.11; p<0.01) (Table 6). PROUNI was also associated with an increase in the chances of a graduate from medical schools being non-white (PR=1.46; 95%CI=1.35-1.58; p<0.01), having concluded public high school (PR=1.83; 95%CI=1.67-2.01; p<0.01), and being from a town with less than 20,000 inhabitants (PR=1.04; 95%CI=1.01-1.07; p<0.05). FIES, by contrast, was associated with a higher probability of the graduate being non-white (PR=1.11; 95%CI=1.08-1.13; p<0.01), having graduated from a public high school (PR=1.02 95%CI=1.00-1.04; p<0.01), and being from a town with less than 20,000 inhabitants (PR=1.03; 95%CI=1.02-1.04; p<0.01).

Another relevant finding was the higher probability of a graduate being of a “non-white” race/color among the graduates from public universities (PR=1.16; 95%CI=1.13-1.19; p<0.01).

Discussion

In Brazil, the Quota Law, PROUNI, and financing through FIES are associated with the increase in diversity in medical schools - racial, social, and including more people from towns with less than 20,000 inhabitants. The Quota Law and PROUNI were the most efficient interventions to reduce social and racial inequalities. Those measures, although more efficient than FIES, are not as far reaching, benefiting together 9.3% of the graduates, whereas FIES benefited almost a third of the graduates from medical schools in 2018.

The predominance of female graduates indicates a tendency of the feminization of the medical workforce, a phenomenon which has been evident in Brazil in recent decades¹⁷17 Scheffer M. Demografia Médica no Brasil 2018 [Internet]. São Paulo: FMUSP, CFM, Cremesp; 2018 [acessado 2020 nov 20]. Disponível em: http://jornal.usp.br/wp-content/uploads/DemografiaMedica2018.pdf.^,2929 Machado MH. Os médicos no Brasil: um retrato da realidade. Rio de Janeiro: Editora Fiocruz; 1997.. Currently, although the majority of the doctors in Brazil are still men, women are the majority among the professionals under 34 years of age¹⁷17 Scheffer M. Demografia Médica no Brasil 2018 [Internet]. São Paulo: FMUSP, CFM, Cremesp; 2018 [acessado 2020 nov 20]. Disponível em: http://jornal.usp.br/wp-content/uploads/DemografiaMedica2018.pdf..

The percentage of graduates who studied in public high schools (24.9%) in 2018 was nearly three times higher than the percentage found in a 2004 study (9%)¹⁶16 Ristoff D. Democratização do campus Impacto dos programas de inclusão sobre o Perfil da graduação. Cad GEA 2016; 9:1-68.. These results are in agreement with other Brazilian studies, which analyzed changes in the profile of the faculties of public universities and indicate that there has been an increase in the number of students from lower income families³⁰30 Cardoso Filho FAB, Magalhães JF, Silva KML, Pereira ISSD. Perfil do Estudante de Medicina da Universidade do Estado do Rio Grande do Norte (UERN), 2013. Rev Bras Educ Med 2015; 39(1):32-40.

31 Silva MLAM, Amaral E, Machado HC, Passeri MRR, Bragança JF. Influência de Políticas de Ação Afirmativa no Perfil Sociodemográfico de Estudantes de Medicina de Universidade Brasileira. Rev Bras Educ Med 2018; 42(3):36-48.

32 Souza PGA, Pôrto ACCA, Souza A, Silva Junior AG, Borges FT. Perfil Socioeconômico e Racial de Estudantes de Medicina em uma Universidade Pública do Rio de Janeiro. Rev Bras Educ Med 2020; 44(3):e090.^-3333 Veras RM, Fernandez CC, Feitosa CCM, Fernandes S. Perfil Socioeconômico e Expectativa de Carreira dos Estudantes de Medicina da Universidade Federal da Bahia. Rev Bras Educ Med 2020; 44(2):e056.. Regardless of these progresses, there is still an underrepresentation of graduates from public high schools in medical schools. This finding is corroborated by the current study, in which nearly one fourth of the medical school graduates in 2018 graduated from public high schools. By contrast, students from public schools account for two thirds of all high schools graduates in Brazil¹⁵15 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2018..

In Brazil, there are few studies analyzing the profile of the students of medical schools according to race/color. In 1997, one study, which analyzed the profile of the students from the Medical School of the Federal University of Espírito Santo found that 68.6% of the students were white³⁴34 Fiorotti KP, Rossoni RR, Miranda AE. Perfil do Estudante de Medicina da Universidade Federal do Espírito Santo, 2007.Rev Bras Educ Med 2010; 34(3):355-362.. Recently, other studies have been conducted in public universities, both state and federal, where affirmative action measures have been implemented³⁰30 Cardoso Filho FAB, Magalhães JF, Silva KML, Pereira ISSD. Perfil do Estudante de Medicina da Universidade do Estado do Rio Grande do Norte (UERN), 2013. Rev Bras Educ Med 2015; 39(1):32-40.

31 Silva MLAM, Amaral E, Machado HC, Passeri MRR, Bragança JF. Influência de Políticas de Ação Afirmativa no Perfil Sociodemográfico de Estudantes de Medicina de Universidade Brasileira. Rev Bras Educ Med 2018; 42(3):36-48.

32 Souza PGA, Pôrto ACCA, Souza A, Silva Junior AG, Borges FT. Perfil Socioeconômico e Racial de Estudantes de Medicina em uma Universidade Pública do Rio de Janeiro. Rev Bras Educ Med 2020; 44(3):e090.^-3333 Veras RM, Fernandez CC, Feitosa CCM, Fernandes S. Perfil Socioeconômico e Expectativa de Carreira dos Estudantes de Medicina da Universidade Federal da Bahia. Rev Bras Educ Med 2020; 44(2):e056.. The percentage of students who were “non-white” in those studies ranged from 22.5% in the Medical Sciences College of the State University of Campinas³¹31 Silva MLAM, Amaral E, Machado HC, Passeri MRR, Bragança JF. Influência de Políticas de Ação Afirmativa no Perfil Sociodemográfico de Estudantes de Medicina de Universidade Brasileira. Rev Bras Educ Med 2018; 42(3):36-48. to 68% in the Federal University of Bahia³³33 Veras RM, Fernandez CC, Feitosa CCM, Fernandes S. Perfil Socioeconômico e Expectativa de Carreira dos Estudantes de Medicina da Universidade Federal da Bahia. Rev Bras Educ Med 2020; 44(2):e056.. Such a variation may be related to the process through which affirmative action was implemented and to differences in the ethnic makeup of the regions where the schools are located. Studies which evaluated the variable race/color among students who entered State medical schools in the cities of Campinas³¹31 Silva MLAM, Amaral E, Machado HC, Passeri MRR, Bragança JF. Influência de Políticas de Ação Afirmativa no Perfil Sociodemográfico de Estudantes de Medicina de Universidade Brasileira. Rev Bras Educ Med 2018; 42(3):36-48. and Rio de Janeiro³²32 Souza PGA, Pôrto ACCA, Souza A, Silva Junior AG, Borges FT. Perfil Socioeconômico e Racial de Estudantes de Medicina em uma Universidade Pública do Rio de Janeiro. Rev Bras Educ Med 2020; 44(3):e090., over a several-year period, indicate that there has been an increase in the ratio of “non-white’ students in more recent years, indicating a discrete increase in racial diversity in medical schools.

The data from this study shows a small drop in “white” graduates when comparing data from the research conducted in 2004 (79.4%)¹⁶16 Ristoff D. Democratização do campus Impacto dos programas de inclusão sobre o Perfil da graduação. Cad GEA 2016; 9:1-68. and in 2014-2015 (77.20%)⁴4 Young ME, Razack S, Hanson MD, Slade S, Varpio L, Dore KL, McKnight D. Calling for a broader conceptualization of diversity: surface and deep diversity in four Canadian medical schools. Acad Med 2012; 87(11):1501-1510. with the results found in 2018 (71.25%). The percentage of “non-white” graduates (28.75%) is still greatly below the percentage of “non-white” people in the general population in 2018 (56.90%)³⁵35 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios Contínua. Características gerais dos domicílios e dos moradores: 2018. Rio de Janeiro: IBGE; 2019..

Among the interventions analyzed in this study, only the admission through a quota system has benefited a majority of non-white graduates. However, the impact of the different quota systems may have heterogeneous results. A study by the State University of Rio de Janeiro conducted an analysis to identify the racial characteristics of the students according to different admission methods. The percentage of “white” students who were admitted to the medical school through open competition was 82%³²32 Souza PGA, Pôrto ACCA, Souza A, Silva Junior AG, Borges FT. Perfil Socioeconômico e Racial de Estudantes de Medicina em uma Universidade Pública do Rio de Janeiro. Rev Bras Educ Med 2020; 44(3):e090.. Among students who were admitted by the system of places reserved for graduates from public high schools and students who were admitted by the system based on family income, the percentage of white students was, respectively, 76% and 71%³²32 Souza PGA, Pôrto ACCA, Souza A, Silva Junior AG, Borges FT. Perfil Socioeconômico e Racial de Estudantes de Medicina em uma Universidade Pública do Rio de Janeiro. Rev Bras Educ Med 2020; 44(3):e090.. The brown students were the majority (77%) only in the method exclusively based on racial quotas³²32 Souza PGA, Pôrto ACCA, Souza A, Silva Junior AG, Borges FT. Perfil Socioeconômico e Racial de Estudantes de Medicina em uma Universidade Pública do Rio de Janeiro. Rev Bras Educ Med 2020; 44(3):e090.. Such a difficulty in reducing inequalities in access to medical schools indicate the need to analyze the several systems of affirmative action in Brazil, since it is possible that affirmative actions based strictly on social criteria are insufficient to reverse the inequalities among the medical workforce. Another relevant aspect is that the percentage of graduates in federal universities in 2018 was about 16%, which indicates the level of implementation of the Quotas Law shortly after its publication, and the challenge of increasing that percentage in the following years.

Only 5.4% of the medical school graduates had been from towns with less than 20,000 inhabitants, while the percentage of Brazilians who lived in towns of that population cohort was 15.4% in 2018³⁶36 Brasil. Ministério da Saúde (MS). DATASUS. População Residente. Censo Instituto Brasileiro de Geografia e Estatística [Internet]. [acessado 2020 jul 7). Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?ibge/cnv/popbr.def.
http://tabnet.datasus.gov.br/cgi/tabcgi.... . Therefore, the results of this study indicate that there is an underrepresentation of students from small towns in medical schools, which points to another dimension of the inequalities in access to medical schools. The increase in the number of places, which has intensified in recent years, has reduced the inequalities among the macro-regions of the country⁷7 Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. Hum Resour Health 2021; 19(1):33.^,3737 Figueiredo AM, McKinley DW, Lima KC, Azeyedo GD. Medical school expansion policies: educational access and physician distribution. Med Educ 2019; 53(11):1121-1131.; however, due to issues of infrastructure in the network of services, the majority of the places available for medical students was located in towns with more than 50,000 inhabitants³⁷37 Figueiredo AM, McKinley DW, Lima KC, Azeyedo GD. Medical school expansion policies: educational access and physician distribution. Med Educ 2019; 53(11):1121-1131.. Therefore, the creation of more places in medical schools in small towns, as an isolated strategy, is insufficient and must be accompanied by other measures.

In Brazil, small towns have a scarcity of doctors, with a ratio of 0.63 doctors for every1,000 inhabitants - this rate is almost 5-fold smaller than that found for towns with more than 500,000 inhabitants⁷7 Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. Hum Resour Health 2021; 19(1):33.. Studies have demonstrated that the fact of having been born in rural areas or small municipalities increases the probability that the doctor ends up working in similar places during their professional life³⁸38 Matsumoto M, Inoue K, Kajii E. Policy implications of a financial incentive programme to retain a physicianworkforce in underserved Japanese rural areas. Soc Sci Med 2010; 71(4):667-671.

39 Shelker W, Zaharic T, Sijnja B, Glue P. Influence of rural background and rural medical training onpostgraduate medical training andlocation in New Zealand. N Z Med J 2014; 127(1403):12-16.

40 Techakehakij W, Arora R. Rural retention of new medical graduates from the Collaborative Project to Increase Production of Rural Doctors (CPIRD): a 12-year retrospective study. Health Policy Plan 2017; 32(6):809-815.^-4141 World Health Organization (WHO). Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: WHO; 2010.. Besides the inequalities in access to medical schools, the small percentage of graduates from small towns may function as a limiting factor in the capability of reducing the scarcity of doctors in places other than large urban areas. Therefore, the implementation of affirmative action measures to guarantee a higher number of students from small towns in medical schools may help reduce inequalities in access to both higher education and medical assistance. It should be emphasized that the PR values for the marker “being from a small town”, found for the Quotas Law and PROUNI, were well below what was found for the markers that evaluated changes in racial composition and the inclusion of students from public high schools, revealing that those measures produced a minimal effect in reducing regional inequalities.

In other countries, there are policies for specifically selecting students from remote regions³⁰30 Cardoso Filho FAB, Magalhães JF, Silva KML, Pereira ISSD. Perfil do Estudante de Medicina da Universidade do Estado do Rio Grande do Norte (UERN), 2013. Rev Bras Educ Med 2015; 39(1):32-40.. One strategy used worldwide is to financially subsidize the education of students from regions with a scarcity of doctors, with those subsidies conditioned to the return to work in remote areas³⁸38 Matsumoto M, Inoue K, Kajii E. Policy implications of a financial incentive programme to retain a physicianworkforce in underserved Japanese rural areas. Soc Sci Med 2010; 71(4):667-671.^,4040 Techakehakij W, Arora R. Rural retention of new medical graduates from the Collaborative Project to Increase Production of Rural Doctors (CPIRD): a 12-year retrospective study. Health Policy Plan 2017; 32(6):809-815.^,4141 World Health Organization (WHO). Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: WHO; 2010.. In Brazil, some affirmative actions were implemented, which contemplated the selection of medical students who were from small towns in the regions near towns where medical schools were created⁴²42 Melo LP, Santos M, Câmara RBG, Braga LP, Oliveira ALO, Pinto TR, Costa PM, Azevedo GD. A Escola Multicampi de Ciências Médicas da Universidade Federal do Rio Grande do Norte, Brasil, no contexto do Programa Mais Médicos: desafios e potencialidades. Interface (Botucatu) 2017; 21(Supl. 1):1333-1343.. However, the impact of those actions is recent and restricted to only a few colleges, limiting the reduction of inequalities as mentioned in this study. Therefore, we suggest implementing affirmative actions that are more encompassing and include selection criteria that can increase the number of students from public high schools and from small towns, especially in regions where there are not sufficient doctors and that are less developed economically.

The analyses were conducted from secondary data from the 2018 Education Census (Censo de Educação) and refer to the graduates who entered medical schools in the previous six years. Therefore, the results of this study describe the effects of the implementation of the described measures in 2012 and 2013. Hence, they do not reflect the impact of variations in the number of graduates who were admitted by the quota system, by PROUNI grants, by loans from FIES in the subsequent years and the effect of the expansion of the number of places in colleges as a result of the More Doctors for Brazil Program (PMMB, in Portuguese).

Another limitation of this study was information left blank regarding some variables, with the greatest losses related to the variables of race/color and place of origin. The losses related to information about race/color can be partially explained by the possibility of the graduates having chosen not to declare their race. However, studies which analyzed other information systems in Brazil also indicate a high rate of undeclared responses for the variable race/color, which suggests that it is difficult to approach racial questions in Brazil⁴³43 Braz RM, Oliveira PTR, Reis AT, Machado NMS. Avaliação da completude da variável raça/cor nos sistemas nacionais de informação em saúde para aferição da equidade étnico-racial em indicadores usados pelo Índice de Desempenho do Sistema Único de Saúde. Saude Debate 2013; 37(99):554-562.. Therefore, it is important that actions are taken by schools to qualify the registry and the planning of actions aimed at reversing the racial inequalities by means of affirmative action initiatives that guarantee opportunities of admission to medical schools and allow medical students to conclude the course.

In the case of the data about the place of origin, it is likely that this information is not highly valued when filling in the education census, in particular due to the lack of a strategy to reverse regional inequalities in terms of the distribution of doctors. There has been a significant difference between the percentage of missing data between private and public universities, which was higher in public institutions. The percentages of missing data about the variable race/color and the variable “type of high school where the graduate studied” were lower for the groups who were admitted through the quota system, most likely because the information is required by federal law. The same is true for the percentage of missing data about the variable race/color for the group benefited by PROUNI scholarships.

Our results indicate positive impacts of the policies adopted in Brazil and some limitations in terms of reversing the identified inequalities, especially racial inequalities. Between the beginning of 2010 and the end of 2018, 19,519 new places were created in medical schools, mostly in private institutions⁷7 Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. Hum Resour Health 2021; 19(1):33.. In the 2016-2018 triennium alone, 10,002 new places were created in private institutions. Therefore, in 2018, 70.4% of the places in medical schools were offered by private schools, and 18.6 by public federal universities⁷7 Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. Hum Resour Health 2021; 19(1):33..

This larger number of places in private medical schools is a limiting factor for the reduction of inequalities, since regardless of the improvements created by programs such as FIES, the high investment required to keep up with the universities’ fees or with the loan installments reduce the possibility that people from lower income families have access to medical schools⁴⁴44 Scheffer MC, Dal Poz MR. The privatization of medical education in Brazil: trends and challenges. Hum Resour Health 2015; 13:96.. Such a situation becomes even worse because medical school courses are full time, with a heavy weekly workload, making it very difficult to conciliate studies with paid activities³⁰30 Cardoso Filho FAB, Magalhães JF, Silva KML, Pereira ISSD. Perfil do Estudante de Medicina da Universidade do Estado do Rio Grande do Norte (UERN), 2013. Rev Bras Educ Med 2015; 39(1):32-40.

31 Silva MLAM, Amaral E, Machado HC, Passeri MRR, Bragança JF. Influência de Políticas de Ação Afirmativa no Perfil Sociodemográfico de Estudantes de Medicina de Universidade Brasileira. Rev Bras Educ Med 2018; 42(3):36-48.

32 Souza PGA, Pôrto ACCA, Souza A, Silva Junior AG, Borges FT. Perfil Socioeconômico e Racial de Estudantes de Medicina em uma Universidade Pública do Rio de Janeiro. Rev Bras Educ Med 2020; 44(3):e090.^-3333 Veras RM, Fernandez CC, Feitosa CCM, Fernandes S. Perfil Socioeconômico e Expectativa de Carreira dos Estudantes de Medicina da Universidade Federal da Bahia. Rev Bras Educ Med 2020; 44(2):e056.. FIES has benefited mostly white students; therefore, in its current format, it does not function as a reducer of racial inequalities.

Moreover, less than 20% of all available places are offered directly at public federal universities, limiting the impact of interventions such as the Quota Law. Therefore, farther reaching affirmative action initiatives, aimed at public and private institutions, and at federal and state universities are required so as to produce an actual reversion of the inequalities. It is also important to qualify the already existing affirmative action policies in order to make them more efficient in the reversal of inequalities concerning the access of black students to high demand college courses such as the medical course.

The Brazilian experience indicates that nationwide measures to regulate the educational system, and private and public financing are efficient in reducing racial and social inequalities in a short period of time, even in the case of countries with severe inequalities. Further studies to evaluate these programs and policies are warranted, from the perspective of analyzing their impacts on the profile of doctors around the country, as well as to identify the necessary adaptations of those strategies to the ongoing social needs. In addition, we suggest that further analysis be conducted to verify if the changes in the profile of the medical graduates and the reduction in inequalities in access to medical schools translate into an increase in the number of doctors in rural areas or less economically developed regions.

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