It is important to highlight that one of our differentiations is our cash flow from operational activities. Adjusted net income for the fourth quarter of 2023 amounted to R$164 million, marking a 28% increase over 2022. For the full year, adjusted net income reached R$591 million, reflecting 11% year-over-year increase. Our adjusted EPS witnessed a robust expansion with 28% growth for the quarter, reaching R$6.37 for the year, reflecting an 11% increase year-over-year. This performance underscored the growth in our net income and discipline capital allocation through business combination. Transitioning to slide number 11 for discussions of key operational metrics by business unit. Beginning with the undergrad programs, our number of medical students witnessed a 19% year-over-year growth, reaching more than 21,000 students with approved medical seats increasing by 12%, primarily driven by the acquisitions and maturations of 340 seats in UNIMA in the beginning of 2023.
Therefore, considering the authorizations by the Ministry of Education of 40 additional medical seats of Faculdades Integradas Padrão, in the city of Guanambi, located in the state of Bahia, Afya reached 100 medical seats on these campuses and 3,203 approved seats as of today. With our net average tickets increasing over 8% year-over-year, reaching R$8,548, compared to R$7,898 in 2022. The last graph illustrates a 24% growth in combined tuition fees, reaching R$3,267 million, up from R$2,635 million from the prior year, 79% of which are related to medicine. This demonstrates that our medical educational business remains and will continue to be the cornerstone of our business in the short and the middle terms, delivering high predictable growth, combined with solid profitability and cash generation.
On the following page, I will present our continuing educational metrics. As previously mentioned, we witnessed another year of significant growth in our continuing educational segment, with more than 60% increase in the number of students compared to last year, reaching 4,976 students. Additionally, for the year, net revenues grew by 35% compared to 2022, boosted by the growth in the number of students. Moving to slide number 13 to discuss the digital service operational metrics. The first graph illustrates our active payers, which are the ones that generate revenues in business to position. With a continuous growth trend, reaching 226,000 paying users, marking 11% growth compared to the last year. The second graph showcases our monthly active users, reaching 268,000 users, representing around 34% of all medical students and physicians in Brazil.
Finally, our digital service net revenue witnessed almost 20% year-over-year increase, reaching R$229 million. Since the beginning of 2022, we also started to break down our digital service net revenue within B2B and B2P segments, with over R$191 million generated from B2P and more than R$39 million from B2B, showing a 64% growth compared to the prior year. And now, transitioning to my final two slides to discuss our cash and net debt positions, and providing more insights into our cost of tax. I presented the net debt reconciliation for 2023. The cash flow from operating activities was allocated to income tax and lease payments, CapEx activities, for the service of the financial debt, for our share buyback program, alongside the additional acquisitions of 15% of FMIT.
Excluding the business combinations of UNIMA, we were able to generate R$391 million as free cash and reduce our net debt in the 12-month period. On my last slide, you can observe a table showing the breakdown of our gross debt and total cost of debt, considering our main debts, the soft bank transactions, debentures, other financial obligations, and accountable payables to selling shareholders. We continue to maintain a low cost of debt that remains below the CDI rates. This concludes our prepared remarks. Strong performance, consistent growth, success in all segments, and public recognition. These are the pillars of our evolutions and our missions to provide an ecosystem that integrates educational and digital solutions for the entire medical journey.
We are proud of our achievements thus far, and we are excited about our future plans. I shall now open the conference for the Q&A session. Thank you.
A – Renata Couto: [Operator Instructions] Our first question will come from Mirela Oliveira from Bank of America. Mirela, you may now talk.
Mirela Oliveira: Good evening, guys. Thank you for your time. I have two questions here. First, if you guys could comment a bit on the competitive environment for 2024, if you have seen any significant change on the candidate per seat on any region. And second, what are the expectations on the Mais Médicos auction in terms of timing after the postponements? And also, if the recent change that established a cap for proposals for the big players changed any expectation you may have on the final results, given that now you’ll be able to submit less proposals. Thank you.
Virgilio Gibbon: Okay, Mirela. Thanks for your question. Regarding your first question about the competition landscape, we just completed our intake process for the first half of 2024. Our ratio of candidates per seat was around almost six candidates per seat, so it was a very strong intake. So we have also not only the intake, but our renewal also completed. So we are running as expected with a very good demand for all of our campuses around the country. So no changing when we compare to last year. Actually, the ratio that we are seeing is even higher than before the pandemic. So that was how we are seeing the competition on the intake process for undergrad, medical undergrad process. Besides that, we are also seeing a very strong intake coming from health programs on our campuses.
