Institutional characteristics associated with meeting the proficiency benchmark in Brazil’s National Medical Education Assessment (ENAMED): a nationwide Bayesian hierarchical analysis

Brazil’s medical education system has expanded at an unprecedented pace, largely through policies intended to increase physician supply and reduce regional disparities. In 2025, Brazil introduced the National Medical Education Assessment Examination (ENAMED), which assesses graduating medical students and provides a proficiency-based measure for institutional evaluation. Unlike previous approaches centered primarily on aggregate performance, ENAMED allows course performance to be examined according to the proportion of graduates reaching a predefined proficiency threshold. We examined institutional characteristics associated with attainment of this course-level proficiency benchmark. We conducted a nationwide retrospective observational analysis linking ENAMED-2025 results to institutional and regulatory characteristics of medical programs. The primary outcome was attainment of a course-level benchmark, defined as ≥ 60% of graduating examinees being classified as proficient. We fitted hierarchical Bayesian models to estimate each program’s posterior probability of meeting this benchmark, accounting for course size and geographic clustering at the state and municipality levels. ENAMED performance varied substantially across institutional segments. Federal and state public medical schools had the highest probabilities of meeting the proficiency benchmark, followed by community-based institutions. Private programs, especially for-profit schools, had lower probabilities of meeting the benchmark. Programs established during the recent expansion period were also less likely to meet the benchmark. Greater authorized enrollment was associated with a lower probability of reaching the ≥ 60% threshold, with the strongest inverse association observed among for-profit institutions. Institutional characteristics were associated with substantial differences in the probability of medical programs meeting the ENAMED proficiency benchmark. Administrative category, timing of program establishment, and authorized enrollment were among the characteristics associated with course-level performance, although the cross-sectional design does not allow these associations to be interpreted as causal. By focusing on the proportion of graduates reaching a predefined proficiency threshold, ENAMED provides a course-level measure that can complement existing indicators used in the evaluation of medical education in Brazil.