AFYA Limited (AFYA): ANSOFF Matrix Analysis [Jan-2025 Mise à jour]

Dans le paysage dynamique de la technologie brésilienne des soins de santé, Afya Limited apparaît comme une puissance stratégique, tirant parti de la matrice Ansoff pour tracer une ambitieuse trajectoire de croissance. En explorant méticuleusement la pénétration du marché, le développement, l'innovation des produits et la diversification stratégique, Afya est sur le point de révolutionner l'éducation médicale et les solutions de santé numérique à travers l'Amérique latine. Leur approche multiforme promet non seulement une croissance progressive, mais un impact transformateur sur la façon dont les professionnels de la santé apprennent, s'entraînent et évoluent dans un écosystème de santé de plus en plus numérique.

AFYA Limited (AFYA) - Matrice Ansoff: pénétration du marché

Développez les plateformes de santé numériques et les services de télémédecine

AFYA Limited a déclaré que 1,2 million d'utilisateurs de plate-forme de santé numérique actifs en 2022. Les revenus des services de télémédecine ont atteint 87,3 millions de R $ au cours de l'exercice, ce qui représente une croissance de 42% sur toute l'année.

Métriques de santé numérique	2022 données
Utilisateurs de plate-forme active	1,200,000
Revenus de télémédecine	87 300 000 $ R
Croissance d'une année à l'autre	42%

Augmenter les efforts de marketing pour l'enseignement médical

Les dépenses de marketing pour les établissements de formation médicale sont passées à 45,2 millions de rands en 2022, ciblant 320 établissements de formation médicale à travers le Brésil.

• Budget marketing: 45 200 000 $ R
• Institutions cibles: 320
• Couverture géographique: 26 États brésiliens

Améliorer le logiciel d'éducation médicale

L'investissement en développement de logiciels a atteint 22,5 millions de rands en 2022, avec 7 mises à jour principales de fonctionnalités mises en œuvre sur toutes les plateformes.

Métriques d'amélioration des logiciels	2022 données
Investissement en R&D	22 500 000 R
Mises à jour des fonctionnalités	7
Taux de satisfaction de l'utilisateur	84%

Développer des partenariats stratégiques

AFYA Limited a établi des partenariats avec 52 universités et écoles de médecine supplémentaires en 2022, augmentant le total des partenariats institutionnels à 187.

Mettre en œuvre des stratégies de prix

Les stratégies de tarification concurrentielles mises en œuvre ont entraîné une augmentation de 28% de l'acquisition des clients, la valeur moyenne du client passant à 3 750 R $ par utilisateur.

Résultats de la stratégie de tarification	2022 données
Augmentation de l'acquisition des clients	28%
Valeur à vie du client	R 3 750 R
Expansion des parts de marché	15.6%

AFYA Limited (AFYA) - Matrice Ansoff: développement du marché

Expansion sur les marchés de l'éducation des soins de santé en Amérique latine

AFYA Limited a déclaré 239,4 millions de dollars de revenus nets pour le quatrième trimestre 2022, avec un potentiel d'expansion sur les marchés latino-américains.

Marché cible	Population	Étudiants en médecine	Potentiel de marché
Colombie	50,9 millions	48,000	42,5 millions de dollars
Mexique	128,9 millions	95,000	78,3 millions de dollars
Argentine	45,8 millions	38,500	35,6 millions de dollars

Stratégie de localisation de la plate-forme numérique

La plate-forme numérique d'Afya dessert 16 000 étudiants actifs avec un taux d'engagement numérique de 92%.

• Adaptation de contenu en langue espagnole
• Modules de curriculum médical localisés
• Scénarios de formation médicale spécifiques à la région

Approche d'investissement des infrastructures

Coût d'expansion des infrastructures estimées: 3,7 millions de dollars pour la nouvelle entrée du marché.

Catégorie d'investissement	Coût prévu
Adaptation à la plate-forme numérique	1,2 million de dollars
Marketing local	$850,000
Infrastructure technologique	1,65 million de dollars

Développement de partenariat stratégique

Couverture de partenariat actuel: 22 associations médicales à travers le Brésil.

• Négociation des accords de partenariat avec 3 associations médicales régionales
• Extension du partenariat projeté: 8-10 nouvelles associations en 2023
• Reach du marché potentiel: 120 000 étudiants en médecine supplémentaires

Analyse du marché cible

Taille du marché de l'éducation médicale hispanophone: 1,4 milliard de dollars en 2022.

Segment de marché	Taux de croissance annuel	Population étudiante
Éducation médicale	7.2%	285,000
Plateformes d'apprentissage numérique	14.5%	156,000

AFYA Limited (AFYA) - Matrice Ansoff: Développement de produits

Créer des outils avancés de simulation de formation médicale alimentés par l'IA

AFYA Limited a investi 3,2 millions de dollars dans le développement de la technologie de formation médicale en IA en 2022. La plate-forme de simulation d'IA de l'entreprise couvre 87 spécialités médicales et compte 12 456 professionnels médicaux enregistrés utilisant la plate-forme.

Investissement technologique	Métriques des utilisateurs	Couverture de formation
3,2 millions de dollars	12 456 utilisateurs	87 Spécialités médicales

Développer des systèmes complets de gestion de l'apprentissage numérique

Le système de gestion de l'apprentissage numérique d'AFYA prend en charge 345 établissements médicaux avec un taux de satisfaction de l'utilisateur de 98,6%. La plate-forme traite 24 000 modules de formation mensuels.

• 345 institutions médicales soutenues
• Taux de satisfaction de 98,6%
• 24 000 modules de formation mensuels

Concevoir des applications mobiles d'abord

Les téléchargements des applications mobiles ont atteint 76 543 au troisième trimestre 2022, avec 62% des utilisateurs accédant au contenu de l'enseignement médical via des plateformes mobiles.

Téléchargements mobiles	Pourcentage d'utilisateur mobile
76,543	62%

Intégrer des analyses avancées

Les fonctionnalités de suivi des performances analysent 1,2 million de mesures d'apprentissage individuelles mensuellement, avec une précision de 89% dans l'identification des domaines de développement des compétences.

Développer la bibliothèque de contenu numérique

La bibliothèque de contenu numérique s'est étendue à 4 567 modules de formation médicale spécialisés, couvrant 93 sous-spécialités médicales distinctes.

• 4 567 modules de formation
• 93 sous-spécialités médicales

AFYA Limited (AFYA) - Matrice Ansoff: Diversification

Développer des services de conseil en technologie de santé pour les institutions médicales

En 2022, AFYA Limited a investi 3,2 millions de dollars dans les services de conseil en technologies de santé. La société a élargi son portefeuille de conseil en santé numérique à 47 établissements médicaux du Brésil.

Métrique	Valeur
Investissement de consultation technologique	3,2 millions de dollars
Clients institutionnels	47 institutions médicales
Croissance des revenus prévus	18.5%

Créer des plateformes de recrutement médical et de gestion des talents

AFYA a développé une plate-forme de recrutement numérique desservant 256 organisations de soins de santé avec 12 345 professionnels de la santé inscrits.

• Utilisateurs de plate-forme: 256 organisations de soins de santé
• Professionnels enregistrés: 12 345
• Revenus de plate-forme annuelle: 1,7 million de dollars

Investissez dans l'analyse des données de santé et les services de recherche

Les investissements en analyse des données sur les soins de santé ont atteint 2,5 millions de dollars en 2022, couvrant 89 projets de recherche.

Métrique d'analyse des données	Quantité
Investissement	2,5 millions de dollars
Projets de recherche	89
Points de données analysés	1,3 million

Explorez les opportunités dans le développement des infrastructures de technologie de santé

L'AFYA a alloué 4,6 millions de dollars à l'infrastructure de technologies de santé, soutenant 34 installations médicales.

• Investissement d'infrastructure: 4,6 millions de dollars
• Installations soutenues: 34
• Taux de mise en œuvre de la technologie: 92%

Développer des solutions de formation d'entreprise pour les organisations de soins de santé

Les solutions de formation d'entreprise ont généré 3,1 millions de dollars de revenus, desservant 167 organisations de soins de santé.

Métrique de la solution de formation	Valeur
Revenu	3,1 millions de dollars
Organisations servies	167
Modules de formation	42

Afya Limited (AFYA) - Ansoff Matrix: Market Penetration

Market Penetration for Afya Limited is all about maximizing returns from the current Brazilian medical education and digital ecosystem. The core strategy here is to drive higher revenue and profit margins from the existing customer base-your medical students and the growing pool of practicing physicians already using your digital tools.

The company's strong performance in the first nine months of 2025 (9M25) shows this strategy is working, with Net Revenue increasing 13.4% year-over-year to R$2,784.3 million (Brazilian Reais) and Adjusted EBITDA rising 18.5% to R$1,291.7 million. That's a solid margin expansion of 200 basis points to 46.4%. You're not just growing; you're getting more efficient.

Increase average tuition ticket prices for existing medical courses.

This is the most straightforward lever in the undergraduate segment. The goal is to push the net average tuition ticket higher than the cost inflation rate, which directly expands your margin. For the nine months ended September 30, 2025, Afya's medical school net average ticket, excluding acquisitions, already saw an increase of 3.4%, reaching R$9,141 per student. The company is guiding for a further tuition increase of 5.0% to 5.2% for the 2026 academic year, which is a clear, deliberate move to boost revenue per student.

Achieve full occupancy across all 3,753 approved medical seats.

Achieving 100% occupancy is pure operating leverage; every filled seat drops more revenue straight to the bottom line. Afya successfully maintained 100% occupancy across all its medical programs in Brazil for the recent intake cycle. This operational excellence is crucial, especially as the total number of approved medical school seats continues to grow. As of November 2025, Afya's total approved medical seats stand at 3,753, up from the previous 3,653 after a recent authorization to add 100 seats at ITPAC Porto Nacional. This means a larger, fully utilized asset base.

Cross-sell Medical Practice Solutions (Afya Whitebook, Afya iClinic) to all 304 thousand ecosystem users.

The digital ecosystem is your second major front for market penetration. The total user base in Afya's ecosystem reached 304 thousand users in 9M25, which includes students, residents, and practicing physicians. The Medical Practice Solutions segment, which includes the clinical decision support tool Afya Whitebook and the clinical management software Afya iClinic, saw revenue growth of over 9% year-over-year. The real opportunity is in converting more of those 304 thousand users from free or freemium models to paying subscribers, especially for high-value services like iClinic, which focuses on clinic management and electronic health records (EHR).

Here's the quick math on the digital opportunity:

• Total Ecosystem Users (9M25): 304,000
• Medical Practice Solutions Revenue Growth (YoY): Over 9%
• Key Products: Afya Whitebook (Clinical Decision Support), Afya iClinic (Clinical Management)

Expand B2B revenue in Continuing Education by securing more corporate partnerships.

The Continuing Education segment is showing impressive results by shifting focus to corporate and institutional clients (B2B). This strategy provides a more stable, recurring revenue stream compared to individual student enrollment. In 9M25, the Continuing Education segment's revenue grew by 11%, reaching R$208 million. More importantly, the B2B revenue within this segment saw a massive increase of 65%, demonstrating the success of securing larger, long-term contracts with hospitals, clinics, and other healthcare organizations for specialized training and graduate programs. That's defintely a high-leverage growth area.

Execute the share repurchase program to boost Earnings Per Share (EPS) growth, which was 28.5% in Q3 2025.

Share repurchases are a financial tool for market penetration, reducing the share count and thus mechanically increasing Earnings Per Share (EPS). Afya's Board approved a new share repurchase program in August 2025, authorizing the repurchase of up to 4,000,000 Class A common shares by the end of 2026. This complements the strong operational performance that drove Basic EPS growth to 28.5% in Q3 2025. Furthermore, the company used R$831.6 million in October 2025 to repurchase all 150,000 Series A perpetual convertible preferred shares from SoftBank, which simplifies the capital structure and eliminates a potential source of dilution.

Market Penetration Metric	2025 Fiscal Year Data (9M25/Q3 2025)	Strategic Impact
Basic EPS Growth (Q3 2025)	28.5% YoY	Directly increases shareholder value and confidence.
Total Approved Medical Seats	3,753 seats (as of Nov 2025)	Expands the fully utilized, high-margin asset base.
Medical School Occupancy	100% full occupancy	Maximizes revenue from existing capacity; zero capacity waste.
Medical Net Average Ticket Increase	3.4% (9M25, excluding acquisitions)	Drives organic revenue growth above inflation.
Ecosystem Users (Cross-sell Target)	304,000 users (9M25)	Large, captive audience for Medical Practice Solutions upselling.
Continuing Education B2B Revenue Growth	65% increase	Secures higher-margin, more predictable institutional revenue.

Next Step: Digital Solutions Team: Create a 60-day campaign to convert 5% of the 304 thousand ecosystem users to a paid Afya Whitebook subscription by year-end.

Afya Limited (AFYA) - Ansoff Matrix: Market Development

Market Development for Afya Limited is all about taking your proven, highly successful Brazilian medical education model and existing digital products into new geographic markets, primarily Spanish-speaking Latin America. This move is the logical next step after consolidating the domestic market, leveraging the strong financial base you built in 2025 to capture a slice of a high-growth regional market.

Honestly, the biggest opportunity here is replicating the digital ecosystem first, since it's the lowest-cost entry point. Your current focus is clearly on Brazil, where you are guiding for full-year 2025 Revenue between R$3,670 million and R$3,770 million, but that capital base is what funds this new market push. You have the cash-a solid 9-month 2025 cash position of R$996.8 million-so now you need to spend it strategically outside of Brazil.

Launch digital solutions (e.g., Afya Whitebook) into Spanish-speaking Latin America.

The digital platform is your beachhead. You already have Afya Whitebook, which is a clinical decision support tool used by approximately 350,000 physicians in your ecosystem, and crucially, a Spanish-language version is available on platforms like Google Play. This is your low-hanging fruit. The Latin America healthcare education market is projected to reach a revenue of US$11,211.4 million by 2033, with a CAGR of 12.9% from 2025. That's a massive, defintely attractive market to tap with an existing product.

The strategy here is to drive user adoption through a freemium model, then monetize with premium subscriptions and targeted Continuing Medical Education (CME) courses. You need to focus on high-density physician markets like Mexico and Colombia first. Your 9M 2025 Adjusted EBITDA margin of 46.4% in Brazil shows the profitability of your model; that margin needs to be the target for your digital segment in LatAm once scale is achieved.

Establish partnerships with local medical schools in neighboring LatAm countries for joint course offerings.

Instead of immediately building physical campuses, start with joint ventures (JVs) for online-only or hybrid programs. This immediately reduces your capital expenditure and acquisition risk. A partnership model allows you to quickly gain local accreditation and cultural relevance, which is essential for medical education. Your Brazilian success is built on a comprehensive ecosystem with over 304 thousand users; replicating this requires local academic credibility.

Focus on offering specialized residency prep courses or Continuing Education programs first. These are shorter, higher-margin offerings that introduce your brand without the regulatory headache of a full undergraduate program. Think about a 70/30 revenue split with the local partner initially, favoring them to secure the deal, then renegotiate as your brand equity grows.

Acquire smaller, established medical education platforms in high-demand, under-served regions outside Brazil.

Acquisitions are your core competency, but you need to shift the target geography. Your recent domestic acquisition of Faculdade Única de Contagem (FUNIC) cost you R$100 million in 2025 and added 60 medical seats. Use this as a benchmark. A similar-sized 'beachhead' acquisition in a market like Chile or Peru, focused on digital or postgraduate education, would be a smart, capital-disciplined entry.

The key is finding a target with strong local regulatory standing and a digital component, then injecting your superior Afya Whitebook and CME content. Your goal is to capture market share quickly, which M&A does best. The table below outlines the risk-return profile of your two primary expansion methods:

Strategy	Initial Investment (vs. R$100M FUNIC)	Time to Market	Primary Risk
Digital Launch (Afya Whitebook Spanish)	Low (Marketing/Localization costs)	Immediate (Product exists)	Low User Adoption/Local Competition
Academic Partnership (JV)	Medium (Curriculum integration/JV costs)	6-12 Months	Cultural/Regulatory Misalignment
Acquisition (Small LatAm Platform)	High (Est. R$80M-R$150M)	12-18 Months	Integration Failure/Overpaying

Pilot online-only Continuing Education programs in new emerging markets.

Continuing Education (CE) is a strong growth driver, and it's inherently borderless. Your digital segment is already a major focus, and this is where you can test new markets outside of LatAm, like Portuguese-speaking Africa or even specific, underserved US Hispanic markets, without a physical footprint. The entire global medical education market is expected to grow at a CAGR of 10.2% from 2025 to 2035.

Start small: launch a few high-demand, niche courses like AI in Diagnostics or Telemedicine Protocols. Use the data from these pilots to identify the next major market for a full digital ecosystem launch. This is pure data-driven expansion.

Next Step: Digital Health VP: Draft a 12-month digital market entry plan for Mexico and Colombia, quantifying the required marketing spend and projected user count for Afya Whitebook Spanish by Q4 2026.

Afya Limited (AFYA) - Ansoff Matrix: Product Development

Product Development for Afya Limited is all about maximizing the value of the existing, highly-engaged Brazilian audience-medical students and practicing physicians-by layering on high-margin digital and specialized educational offerings. This is a low-risk, high-return strategy because you're selling more to customers you already have.

The core focus in 2025 has been on embedding Artificial Intelligence (AI) into the physician's workflow and expanding the Continuing Education segment, which together drove the Medical Practice Solutions revenue to R$ 128.2 million in the first nine months of 2025, a 9.3% year-over-year increase. That's a strong signal the market is ready to pay for productivity gains.

Accelerate the rollout of AI-enabled enhancements across the digital platform.

Afya is using AI not just as a feature, but as a core utility across its digital ecosystem, specifically in Afya Whitebook, Afya iClinic, and ReceitaPro. The goal is clinical productivity. For instance, the AI integrated into Afya iClinic can automate tasks like pre-filling electronic health records (EHRs), potentially saving a healthcare professional up to 40% of their time. This is a crucial value proposition that justifies the premium subscription cost and drives the expansion in Clinical Management active payers. The AI-driven updates in Afya Whitebook ensure clinicians get real-time access to the latest, evidence-based treatment guidelines, which is a non-negotiable for medical practice.

Expand the Residency Journey product line with new specialization courses and e-books.

The Residency Journey product line is a key component of the Continuing Education segment, which saw its revenue climb to R$ 207.6 million in 9M25, reflecting a 10.6% year-over-year growth. This growth is directly tied to the increase in Graduate Journey students. The strategy here is simple: capture the physician's wallet share immediately post-graduation. By continuously rolling out new, high-demand specialization courses and e-books, Afya keeps its audience captive and monetized. This is defintely a high-margin area, as the content is largely digital and scalable.

Develop new, high-margin clinical management software features for Afya iClinic active payers.

The Medical Practice Solutions segment's growth in 2025 was explicitly driven by an expansion in Clinical Management active payers and a more favorable product mix. The focus is on moving beyond basic EHR functionality to providing comprehensive practice management tools. New features include automated financial control, generation of TISS standard guides for insurance claims, and recurrent anticipation of receivables-all of which are sticky, high-value services. The introduction of iClinic Assist, an AI-powered solution for the EHR, is the latest feature designed to further solidify this revenue stream.

Launch new non-medical healthcare graduate programs, like dentistry or veterinary medicine, in existing campuses.

While Afya is primarily a medical education powerhouse, it already operates programs in adjacent health sciences like Dentistry, Nursing, and Management. The Product Development strategy here is to launch new, specialized graduate programs in these existing non-medical fields to maximize the utilization of campus infrastructure and faculty. This leverages the brand equity of an established medical education group. In 2025, the Undergraduate segment continues to be the largest revenue driver, with 25,706 medical school students and a net average ticket of R$ 9,141 per month (excluding acquisitions) in 9M25, providing a massive, stable base to cross-sell these new graduate programs.

Monetize the new Instituto Afya by offering specialized research and fellowship programs.

The launch of Instituto Afya in 2025 is a strategic long-term product development move. It is positioned as a high-end, specialized offering that aligns with the UN 2030 Agenda, focusing on chronic disease management. Monetization comes from specialized research and fellowship programs that combine virtual training with real-world data analytics. This model allows Afya to tap into premium, institutional funding and charge higher fees for specialized, AI-powered research programs, creating a new, high-margin revenue stream that also enhances the company's ESG (Environmental, Social, and Governance) profile.

Here's the quick math on the digital and education segments' contribution to the 2025 strategy:

Metric (9M 2025)	Amount (R$ million)	YoY Growth	Product Development Focus
Net Revenue (Total)	R$ 2,784.3	+13.4%	Overall financial capacity to fund product rollouts
Continuing Education Revenue	R$ 207.6	+10.6%	Residency Journey expansion and new graduate programs
Medical Practice Solutions Revenue	R$ 128.2	+9.3%	Afya iClinic and Afya Whitebook AI enhancements
Adjusted EBITDA Margin	46.4%	+200 bps	High-margin digital products are driving margin expansion

Afya Limited (AFYA) - Ansoff Matrix: Diversification

This is the highest-risk, highest-reward quadrant: new products for new markets. Afya Limited's core business is strong, with 2025 full-year net revenue projected between R$3,670 million and R$3,770 million, but true long-term growth means moving beyond the Brazilian medical education oligopoly.

The strategic move here is exporting the digital ecosystem (Afya Whitebook and Afya iClinic) to a larger, more fragmented international market, or acquiring a non-medical education platform in Brazil to diversify the revenue stream away from the highly regulated medical sector. This requires a significant capital allocation, especially since the company's cash position was R$1,099.1 million as of the first half of 2025.

Enter the US or European market with a specialized, proprietary digital health solution defintely focused on physician practice management.

Afya's existing digital solutions, which serve over 302,000 users in the Afya ecosystem and include Afya Whitebook (a clinical decision support tool) and Afya iClinic (a practice management software), are prime for this export. The core product is proven, so the challenge is regulatory compliance (like the European Union's General Data Protection Regulation or GDPR) and market entry cost.

The opportunity is massive. The global Practice Management System (PMS) market is calculated at USD 17.02 billion in 2025, with the US market alone expected to hit a CAGR of 10.20% from 2025 to 2034. In Europe, the overall Digital Health market is valued at USD 96.68 billion in 2025, with cloud-based solutions capturing a 57.62% share in 2024. A successful US launch could add $50 million to $100 million in new annual recurring revenue within three years, a material increase against the 2025 revenue guidance.

Acquire a non-medical, professional education group in Brazil to enter a new vertical like law or engineering.

While Afya's M&A focus has been on consolidating medical seats (like the mid-2025 acquisition of FUNIC for R$100 million), entering the broader professional EdTech market in Brazil offers a less regulated growth path. The Brazil EdTech market size was valued at USD 5.41 billion in 2024 and is expected to grow at an 11.7% CAGR through 2033. This high-growth environment is perfect for deploying Afya's proven digital learning infrastructure.

A target acquisition in a field like law or engineering would immediately diversify the student base and provide a new revenue stream. The key is finding a platform with a high percentage of distance learning (EAD) students, as EAD courses accounted for approximately 49% of total Brazilian higher education enrollments in 2024, offering superior margin potential.

Develop a venture capital arm to invest in early-stage health tech startups outside of Brazil.

A dedicated corporate venture capital (CVC) arm, perhaps with an initial fund of $50 million, would give Afya an early-mover advantage in disruptive technologies outside its core geography. This is a strategic hedge against future market disruption. The goal is to invest in Seed or Series A health tech companies in the US or Europe focused on AI diagnostics or clinical decision support, which are currently dominating digital health funding clusters.

Form a strategic alliance with a global pharmaceutical company for accredited drug-specific training programs.

This is a low-capital, high-impact diversification move. Afya could partner with a major global pharmaceutical firm like Pfizer or Merck to create accredited Continuing Medical Education (CME) content focused on new drug protocols or therapeutic areas. The pharma company gets access to Afya's 160 thousand Whitebook physician users and its vast network of medical students, while Afya generates a new, high-margin B2B revenue stream.

Here's the quick math on the market opportunity for a digital export strategy:

Diversification Opportunity	Target Market	2025 Market Size / CAGR	Afya's Core Asset
Digital Health Export (Afya iClinic/Whitebook)	US Practice Management Software	USD 17.02 billion (Global PMS Market Size 2025)	26,000+ professionals using iClinic; 160,000+ Whitebook users
Digital Health Export (Afya iClinic/Whitebook)	Europe Digital Health Market	USD 96.68 billion (2025 Market Size); 18.11% CAGR	Proven cloud-based platform for physician workflow
Non-Medical Education Acquisition	Brazil EdTech Market	USD 5.41 billion (2024 Market Size); 11.7% CAGR	Centralized EAD infrastructure and M&A expertise

What this estimate hides is the regulatory complexity; for example, the European Health Data Space (EHDS) coming in 2025 will define new interoperability and data-sharing standards that Afya must meet. Still, the growth potential in these new markets dwarfs the domestic medical education growth rate.