Higher tuition linked to stronger exam scores at Lima’s private medical schools

Medical schools in Metropolitan Lima charge wildly different amounts for the same degree, and a new study suggests that within the private sector, what students pay is closely tied to how their institutions perform on Peru’s national medical licensing examination. The finding, published in Frontiers in Education, comes from an ecological, institutional-level correlational analysis of all 11 licensed medical faculties in the capital that participated continuously in the National Medical Examination (ENAM) between 2021 and 2024.

The research team, led by Renzo Santiago Hidalgo Manrique of Ricardo Palma University’s Institute of Research in Biomedical Sciences, drew on official registries from SUNEDU, Peru’s higher education regulator, and DIGEP-MINSA, the health ministry directorate that oversees health personnel records. Rather than tracking individual students, the study aggregated data at the institutional level, using a fixed quota of 25 graduate records per faculty across the study period, for a cumulative sample of 275 physician records. Graduate identities and degree authenticity were verified against SUNEDU’s national registry of degrees and titles.

The financial spread was enormous. Over the seven-year, 14-semester curriculum, cumulative tuition ranged from S/ 509.60 (about $135.89 USD) at the public Universidad Nacional Federico Villarreal to S/ 430,780 (about $114,875 USD) at the private Universidad Peruana Cayetano Heredia. Public universities charge only administrative and enrollment fees under Peru’s constitutional mandate for free public education: the total direct cost was S/ 2,604 (about $694.40) at Universidad Nacional Mayor de San Marcos (UNMSM). Among private institutions, Universidad Peruana de Ciencias Aplicadas followed Cayetano Heredia at S/ 396,550 ($105,746), with Universidad Peruana Unión, Universidad Científica del Sur, Universidad de Piura, Universidad de San Martín de Porres, Universidad Privada San Juan Bautista, Universidad Ricardo Palma and Universidad César Vallejo filling out the spectrum, the last at S/ 71,400 ($19,040). All figures were converted at a mean exchange rate of 3.75 soles per dollar.

On the examination side, the researchers computed multi-year consolidated mean scores on the ENAM’s 0-to-20 scale. Cayetano Heredia led with a consolidated mean of 15.16 points (standard deviation 1.20), followed by the Lima campus of Universidad de Piura at 15.05 (1.35), based only on 2023 and 2024 cohorts because that program opened recently. Universidad Peruana de Ciencias Aplicadas scored 14.74 (1.57), UNMSM 14.49 (1.45), and Universidad Peruana Unión 14.46 (1.44). A middle tier of private schools clustered between 13.06 and 13.86 points, while Universidad César Vallejo recorded the lowest consolidated mean at 11.58 (0.76). Mean scores rose across cohorts in 2024, but relative institutional rankings stayed consistent over the four years.

The statistical core of the study lies in how tuition and performance correlate. Across the full census of 11 institutions, Spearman’s rank correlation, the study’s primary estimator because it is robust to extreme leverage points, showed a moderate positive monotonic association (ρ = 0.655, p = 0.029). Pearson’s linear correlation, by contrast, fell just short of significance (r = 0.596, p = 0.053), a discrepancy the authors attribute largely to the tuition-free public universities, which achieve top-tier scores at marginal direct cost and therefore break the linear pattern.

When the analysis was restricted to the nine private institutions, the association strengthened markedly: Spearman’s ρ rose to 0.850 (95% confidence interval 0.43 to 0.97, p = 0.004) and Pearson’s r to 0.887 (p = 0.001). A sensitivity analysis excluding Universidad de Piura, whose truncated two-year evaluation window could have introduced temporal distortion, confirmed the pattern, with ρ = 0.952 (95% CI 0.75 to 0.99, p < 0.001) in the private sector and ρ = 0.648 (95% CI 0.03 to 0.91, p = 0.043) in the overall sample excluding that campus. The authors emphasize that these are rank associations at the institutional level, not evidence of a causal link between spending and competence.

The public sector’s strong showing is a central interpretive point. The authors argue that public institutions such as UNMSM achieve high standardized performance through extreme admission selectivity, with thousands of candidates competing for limited seats, filtering for cohorts with superior pre-existing academic ability, and through state subsidization of operational costs, hospital training agreements and faculty compensation. Tuition-free access, they note, does not mean zero educational cost; it means the cost is borne by the national budget rather than the student. The study’s stratified design was intended to separate these two dynamics, isolating the private market where tuition, rather than subsidy, drives the resource base.

Within the private sector, the data also revealed a performance plateau. High-tuition institutions consistently led the rankings, but mid-tier private universities requiring cumulative investments between roughly $50,000 and $85,000 showed consolidated averages compressed into a narrow band between 13.06 and 13.86 points. The authors connect this to an ongoing debate in medical education about whether high tuition barriers and reliance on commercial preparatory tools can sometimes reflect market positioning rather than proportional improvements in training quality. They cite the position that financial resources translate into clinical competence only when paired with structured pedagogical design, deliberate practice, systematic feedback and formal integration of objective structured clinical examinations, not through infrastructure and technology alone.

The study carries important methodological caveats, which the authors state plainly. Because the design is ecological and cross-sectional, using aggregated institutional metrics, the findings cannot be extrapolated to individual student competence, and the authors explicitly warn against the ecological fallacy. Official registries do not provide individual-level baseline covariates such as secondary school grades, entrance examination percentiles or socioeconomic status, which prevented more sophisticated modeling that could isolate net institutional value-added. Cumulative tuition also serves only as an aggregate financial proxy, ignoring scholarships and departmental spending breakdowns. The study is geographically limited to Metropolitan Lima, which the authors note accounts for over half of Peru’s medical students and test-takers, but generalization to regional universities should be cautious. The wider confidence intervals reflect the small number of institutions, and the authors frame the results as exploratory evidence of tuition-performance alignment rather than definitive proof of structural determinism.

Why does the ENAM matter so much in Peru? Following Ministerial Resolution No. 264-2024/MINSA, the National Health Competency Assessment now handles the binding allocation of positions in the mandatory rural and marginal urban health service. The ENAM, administered by the Peruvian Association of Medical Schools, remains the foremost statistical predictor of success on the National Medical Residency Examination, and ranking in its top third is described as essential for gaining access to limited positions in highly competitive specialties such as neurology, gastroenterology, general surgery and neurosurgery. The authors say their findings, while preliminary, argue for financial transparency in higher education, better guidance for prospective medical students, and informed policy discussion on institutional accountability and educational quality oversight, particularly in a system where the medical degree constitutes the highest economic barrier in the entire Peruvian educational system.

Subject of Research: The association between cumulative undergraduate tuition costs and institutional performance on Peru's National Medical Examination among medical faculties in Metropolitan Lima

Article Title: Financial investment in undergraduate tuition and institutional performance on the National Medical Examination in Metropolitan Lima, Peru: an ecological correlational study

Article References: Hidalgo Manrique, R. S., Ordaya Villanueva, L. A., Morillo Blas, P. A. V., Atúncar Quispe, F. A., & Vela-Ruiz, J. M. (2026). Financial investment in undergraduate tuition and institutional performance on the National Medical Examination in Metropolitan Lima, Peru: an ecological correlational study. Frontiers in Education, 11, Article 1922365. https://doi.org/10.3389/feduc.2026.1922365

Image Credits: AI Generated

DOI: 10.3389/feduc.2026.1922365

Keywords: medical education, Peru, tuition costs, ENAM, Metropolitan Lima, ecological study, private universities, public universities, SUNEDU, licensing examination, health equity, institutional performance