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Dear Editor,
In the current context of the COVID-19 pandemic, the media has widely addressed discussions and views on Peru's public health. A program transmitted on national television, called El país que cuidamos ¿Cómo lograr un acceso universal a la Salud en el Perú? (The country we care for. How to achieve universal access to health care in Peru?), shared the opinion of a renowned doctor who stated that the period between 1960 and 1990 represented "lost years" in the history of Peru's National Health System. Such a statement demonstrates the need to verify the information provided to the population since, as I will explain throughout this letter, significant achievements were accomplished in that period regarding the Peruvian Health System, and they are not acknowledged by said professional.
Precisely, the National School of Public Health (ENSAP by its acronym in Spanish), a decentralized institute affiliated with the Ministry of Health of Peru (MINSA), was established between 1960 and 1990,1 and the National Health Services System, through Decree Law 22365 of 1978, was created based on the Declaration of Alma-Ata.2,3
The National Health Services System effectively coordinated all health institutions in the country over a year and a half through the National Health Council and multiple regional councils, which enabled, on the one hand, making significant progress in health equity -such as the creation of the first National Primary Health Care Plan and the National Basic Medicines Program-, and, on the other, developing and approving the Social Security Health Benefits Scheme. It should be noted that this scheme extended the coverage to the relatives of the insured person and independent contractors, as stated in Decree-Law 22482.4 This was an innovative process that was recognized by the Director General of the World Health Organization, Halfdan T. Mahler after his visit to Peru in 1980.5-7
Moreover, the constant efforts made by the professors and members of ENSAP, at the academic and operational level, to position training and professional scientific practice of health and public health in the country were evident. Since medicine is an interdisciplinary science, such positioning was based on the general systems theory and its systemic and prospective approach to addressing individual and collective health problems.
In addition, the ENSAP helped establish a coordinated national health system based on a plausible health care complexity level scheme and participated in the implementation of the career in public administration, also called the health career, to encourage efficient administration in this context. This was done in accordance with the Legislative Decree 276.8
In Peru, given the poor response of the competent authorities to the current COVID-19 pandemic, the media have focused on the lack of administrative capacity of the government to adequately address the situation. However, in my opinion, this lack of competence would not have occurred if two institutions, which operated during the "lost years", were still active.
The first institution is the Higher School of Public Administration (ESAP), created on December 10, 1968, through Decree Law 172979 as a body affiliated with the Presidency of the Republic. Its main objectives were to train and improve the skills of civil servants at all administrative levels and promote the training of public administrators in universities and other higher education centers.
It is worth mentioning that in 1989, through Legislative Decree 534,10 the Organic Law of the National Institute of Public Administration (INAP) was amended, and Article 18 established that the ESAP was a decentralized body of the INAP. Back then, the school oversaw the designing and implementation of higher education programs in government management, as well as the training of senior public officials and servants, and an annual budget program was created for that purpose. In this context, the ESAP was authorized to issue specialization and master's degree programs related to government management.
In 1995, during the government of Alberto Fujimori, the INAP ceased its operations and the ESAP was attached to the Ministry of Labor and Employment Promotion.11 However, this provision was not fulfilled, and the school closed and ended up disappearing that same year, along with its vast experience in public management training.
The second institution is the INAP, which was created in 1973 by Decree Law 2031612 as a governing body for the Public Administration Reform process in the country. This institute operated under the direction of the National Office for Staff Rationalization and the National Office for Personnel Management, both of which were specifically created to implement this reform along with the ESAP. Nonetheless, as mentioned above, Law 26507 of 199513 provided for the cessation of its activities and subsequent closure. For this purpose, a dissolution and transfer commission was appointed to transfer the INAP documents to the Presidency of the Council of Ministers, as established in Resolution 001-CDT/PRES of 1996.14
This brief historical account allows us to say that referring to the 1960-1990 period as the "lost years" implies denying the achievements of the Peruvian Health System during that time and ignore the fact that political actions based on the patient and not on the disease were optimized in that period through the modernization of public administration. I would like to highlight some of the actions carried out by the institutions mentioned above that made great impact on the Peruvian public health system between 1960 and 1990.
Firstly, between 1964 and 1968, the ENSAP developed 9 courses and lecture series for physicians (2 months to 12 months), 4 courses for nurses (2.5 months to 10 months), and 4 courses for other professionals (2 months to 9 months).
The ENSAP dictated the norms according to which 10 training courses for non-professional staff should be conducted in different locations of the country, taking into account the local needs of the area and health units.
With regard to public health research and collaboration, in 1967, the ENSAP initiated a study on population dynamics in three localities belonging to the three natural regions of the country.
Concerning collaboration, the ENSAP supported the Ministry of Health's central level units by giving its technical opinion on multiple specific issues or by taking part of different standing or temporary committees.15
The ESAP, for almost three decades, served as a center of specialization in public affairs.
The graduates were one of the greatest strengths of the ESAP, so much so that a special course was designed for almost every topic of public administration specialization, the most important being the master's degree in Public Administration. It should be noted that in the 1980s, the master's degree offered by the ESAP was the only one that specialized students in public management and, therefore, it had the training and education monopoly of the public service since no university developed courses, programs, or master's degrees on these topics.
The quality of the training offered by these public institutions in Peru is an asset that should have been kept over time since it would have been useful to optimize activities and appointments of public servants to the benefit of the citizens.1 Such is the case of other Latin-American and European countries, where national public administration institutes actively promote studies on the state and public administration aimed at major issues related to organizations, management and public employment.
In view of the evidence on the advances in health equity achieved by the ENSAP between 1960 and 1990, I would like to refer to my work entitled El Legado de Escuela de Salud Pública del Perú (The Legacy of the Peruvian Public Health School),16 for it is a testimony that attempts to analyze the ups and downs that this institution, whose praxis was centered in the hospital, experienced to fulfill its objectives in the face of a logical hegemonic reality of medicine (based on clinical logic and the mechanical biology paradigm.)
When analyzing the current situation in Peru and based on the historical context described, that moment could be called a "period of obscurantism" since it includes moments of struggle and resistance to the most recent scientific evidence.
In this context, the development and expansion of interdisciplinary sciences in the health sector must be encouraged to achieve the scientific knowledge necessary to work efficiently and effectively during health emergencies such the COVID-19 pandemic. This will only be possible in the light of our reality and will allow the Peruvian population to regain confidence in its health system. In this regard, Popper points out that the theory and praxis of modern sciences do not study subjects but problems, and that these problems can go beyond the boundaries of any object of study or discipline.17
In short, I believe it is necessary to rethink the expression "lost years" since, according to Rabelais,18 time makes all things mature and makes them evident; in other words, time is the father of truth. In view of this, I reassert my professional position to recognize the achievements of the Peruvian Health System between 1960 and 1990, based on democratic principles, human rights and civic values that especially promulgate freedom, truth, honesty, and equality because they are intended to serve the population.19
In this way, respectfully and from an ethical deontological perspective, I wonder if the years we spent with the students of the ENSAP during our training process as health professionals were actually "lost".20 I would like to invite the media to check more carefully the information they disclose, because, as demonstrated here, it may not be entirely true. On the contrary, it may discredit significant achievements made by health institutions; that is what the country needs least at a time of health crisis like the one we are living in.
