Estimation and distribution of undergraduate and postgraduate programmes
One of the consequences of the unequal distribution of programmes is the migration of students. Since many young people from disadvantaged communities see education as a way out of poverty, the search for better education is one of the reasons they migrate . However, it is not certain that these professionals will return to their place of origin, as cities where there is more opportunity for education tend to offer better and more employment opportunities . Thus, the unequal distribution and concentration of mental health programs in the capital city reinforce migration in those who want to pursue such programs and demotivates those who want to stay in their regions of origin.
In addition, we found few undergraduate medical technology programmes in the area of speech and occupational therapy as well as social work. The shortage of the first two programmes is reflected in the Ombudsman's report in Peru . This implies a danger for services dedicated to children and the elderly. This situation is associated with the fact that the demand for certain areas of medical technology is not visualised by the MOH, replacing the functions of medical technologists with other professionals and resulting in few universities offering the programmes .
Characteristics of undergraduate and postgraduate programmes
At the undergraduate level, public universities offer free tuition, but they are very selective and require a high level of preparation  making it difficult for many students to enter. Although private universities are less selective, their average monthly cost is more than US$ 111.95, which varies according to the programme and the university chosen . In this context, the economic factor stands out as a trigger for the interruption of studies, as in 2018, 47.7% of Peruvian students who interrupted their studies were from the lowest economic level .
In terms of the quality of universities, rankings are currently used. Among them, the international higher education consultancy Quacquarelli Symonds (QS) based on 6 indicators (e.g. academic reputation and employer reputation) presented the QS World University Rankings 2022 . This ranking included 8 Peruvian universities, of which five (PUCP, UPCH, UNMSM, UPC, USIL) have health careers. Of these, only UNMSM is public, but it has a very high selectivity, in 2018 it had 60,070 applicants and offered only 7,017 vacancies . This makes access to quality education difficult, with few universities in the ranking, all located in the capital and mostly private.
As far as second speciality programmes are concerned, we found similarities and differences with programmes in other countries in terms of the duration, place of training, the form of teaching, supervision and distribution.
In Asia, the training of psychiatrists lasts one year longer than in Peru , and the place of training is similar, such as university facilities, psychiatric units of general or mental health hospitals ,. Also, one approach to training in psychiatry in Japan is to offer more active, clinical, social and behavioural science-based learning , while in Peru the biological paradigm predominates . For whom, normal is the standard for a given situation, becoming a statistical health pattern, adopting an excluding and differentiating character, generating limitations in health care and not adjusting to the biological-ecological and social reality ,. The biological paradigm is important, but it cannot encompass the complexity of the human disease process and treatment . On the other hand, in Europe, the European Union of Medical Specialists governs the quality control mechanisms of training programmes , while in Latin America each country has its institutions and standards.
In Spain, there is a heterogeneous distribution of training programmes in nursing, with a duration of one year and no standard for the teaching of the speciality . Similarly, in Peru, most speciality programmes are offered in the capital city of Peru, and there is no standard for teaching. In contrast, the UK has developed speciality programmes with criteria such as defining the target population, including evidence-based approaches, developing core competencies from the chosen approach and others . It would therefore be more appropriate to establish standards that allow for better professional training through mechanisms that guarantee continuous supervision, quality assurance in training programmes, as well as validation that authorises the transfer of a mental health service provider from one country to another.
In terms of psychology training in Latin America, Argentina stands out for expanding the number of sites, with postgraduate programmes focused on clinical education to ensure coverage in the offer of professional training , and the implementation of e-learning during the pandemic to reinforce clinical training through telehealth services . Peru, on the other hand, has second speciality programmes centred in the capital city and largely theoretical, but having programmes in hospital settings or centres with guaranteed internships would consolidate the clinical competencies of health professionals ,,. In this regard, it is emphasised that training should be designed to prepare healthcare workers to perform their work in real-life conditions and thus prevent ineffective and inadequate outcomes during treatment by increasing the likelihood of recovery of users ,.
Mental health reforms in Latin America seek a restructuring of hospital care services based on a community-based model . In Peru, the shift from hospital care to community care to strengthen the role of the community in the treatment and rehabilitation of patients with mental disorders and increase access to care is highlighted ,,. This reform is generating progress with respect to the role of physicians and nurses. However, in the case of psychologists, there is no specific regulation that obliges hospitals or primary care centers to serve as a training environment based on professional quality standards, which could mean that they have fewer training opportunities compared to other health professionals.
On the other hand, as for the cost of second speciality programmes, these range from 3.1 to 51.6 times the minimum living wage, an expense that is borne by the professionals and which influences their decision on which programme to choose. Thus, for a group of medical students, the choice of a second speciality was mainly based on salary (23.6%) and job opportunities (19.7%), for a few of them on calling (8.9%) .
Finally, it is worth mentioning that the programmes require teaching standards, but this was only found for second speciality medicine programmes and not for other health professionals. While the National Superintendence of Higher Education in Peru is evaluating the basic quality conditions of medical training programmes , this evaluation needs to be extended to programmes focusing on mental health. It is important to have an entity responsible for monitoring them to ensure that they maintain basic quality conditions.
Public health and education implications
In Peru, CMHCs as first-level centres, with an interdisciplinary team and a community approach , has generated significant levels of care at a lower cost than Specialised Psychiatric Hospitals. However, staff shortages hinder the expansion of health care, the implementation of policies and the structuring of health systems . Measures need to be put in place to increase access to training programmes required by understaffed regions.
One proposal to increase access to training programmes is the decentralisation of supply and the evaluation of the relevance of selection and admission criteria . A reference for increasing access to higher education was Brazil, which financed a network of public universities and tried to consolidate a network of public distance universities . Another strategy to cope with the concentration of programmes in a few regions and geographical barriers is the e-learning model. However, this option requires access to the Internet, electronic devices such as computers , specialised staff to design the programmes, adapt e-learning to the reality of the participants  and train teachers . Also, the model may limit learning to theoretical aspects or digital interventions, but one option is to combine online classes with rotations in hospitals, which would require contact with hospitals or first level centres for the development of classes and practices.
Another proposal, given the lack of programmes, is to prioritise entry vacancies for people from remote or low-income regions . Ensure the permanence of university students, as Chile has done by implementing scholarships to help cover certain expenses of university life  or expand education by having the central or regional health system establish agreements or support applicants with the payment of existing programmes in private universities.
Strengths and Limitations
The strengths of this study are the search for programs at the level of the campuses and branches of the universities, as well as the parallel search for programs on the University Information System platform and the universities' web pages. The former made it possible to estimate the number of programs more accurately and the latter made it possible to avoid overlooking recently created programs.
As for the weaknesses of the study, firstly, universities that were not licensed or were under evaluation by the National Superintendence of Higher Education were not considered. However, this should not affect research considerably, as unlicensed universities often cease their activities and their programmes cease to exist, while universities in the process of licensing have not yet demonstrated that they meet minimum quality criteria. Secondly, some universities' websites do not provide complete information on the programmes, but we were able to find information on most of them. Thirdly, while our study allows us to have an overview of the educational offer, it does not allow us to have an overview of the current number of professionals available and to assess whether or not more supply is needed.