Towards resilience: Professor Mika Salminen, Finnish Institute for Health and Welfare

As the global health community continues to examine how prepared we were for a pandemic, this week’s episode asks – how can we move the conversation forward to future resilience, and what systems can be put in place to ensure we can withstand future pandemics?

Our guest this week is Professor Mika Salminen, the Director of Health Security at the Finnish Institute for Health and Welfare. We discuss the World Health Organization’s Joint External Evaluations (JEEs) and States Parties Annual Reports (SPARs), and what he’s learned through his work focussing on measurement systems of health outcomes. 

Much of the dialogue around Covid-19 is around what is currently happening, but Professor Salminen discusses the importance of thinking about what we can do better to safeguard against the next pandemic so that we do not need the prolonged global shutdowns that have had major consequences on our health, welfare, and economies – particularly in low-income countries. 

This conversation was recorded at the recent Global Health Security Conference in Singapore. We hope you join the conversation at @CentreHealthSec and follow Professor Salminen’s work at @mika_salminen and @THLresearch.

Transcript

Please note: We provide transcripts for information purposes only. Anyone accessing our transcripts undertake responsibility for assessing the relevance and accuracy of the content. Before using the material contained in a transcript, the permission of the relevant presenter should be obtained.   

The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.

Nick Harris 00:00

Hello, and welcome to Contain This. I'm Nick Harris, an adviser from the Indo-Pacific Centre for Health Security. Before this week's episode, I want to acknowledge the Traditional Owners and Custodians of country throughout Australia and the region. We recognise their continuing connection to land, waters and community and we pay our respects to Elders past, present and emerging. I recently attended the Global Health Security Conference in Singapore where I spoke to virologist Professor Mika Salminen about his work with the World Health Organization's Joint External Evaluations (JEEs) and State Party Annual Reports (SPARs). His work focuses on measurement systems of health outcomes, particularly in the context of COVID-19 and other potential global pandemics. Professor Salminen is currently the Director of Health Security at the Finnish Institute for Health and Welfare, a research and development institute, which aims to promote the health and welfare of Finland's population. Prior to joining the institute more than 10 years ago, he was with the European Centre for Disease Prevention and Control. He also holds the position of Adjunct Professor of Virology at the University of Helsinki. The global health community continues to examine how prepared we were for a pandemic. But Professor Salminen argues that the conversations taking place now should be geared towards future resilience, particularly in terms of countries’ health systems. He asks how we can put in place systems and processes to prevent us needing measures like prolonged shutdowns of global society, and what this would mean for withstanding future pandemics. 

Nick Harris 01:45

Thanks for for joining us, Mika. I really appreciate your time. I was wondering whether you could give us a bit of a summary of the work, the recent work that you've been doing on the Joint External Evaluations and SPARs and the correlation or not with performance. And if you could give us a bit of a summary too of what you led you into the work.

Professor Mika Salminen 02:11

A couple of years back, before the pandemic, we did some work, looking at the JEE scores and the SPAR scores, the first version, SPAR scores, and I think the second version JEE scores across countries and compared them with data from the World Bank, on indicators on health outcomes. And then on the other hand, on social democratic graphic indicators, risk factors, and enablers and, and things like that. And we were interested to see if there was any kind of correlation in, in the simple question would be: are rich countries better than than poor countries? And if you have a good score in the JEE, will that correlate with better health outcomes? And basically, the question is pretty much yes. Not quite, so simple. Mostly, it's yes. Or if you look at the JEE SPAR indicators, and the health outcomes and especially then communicable disease outcomes, there is a very clear linear correlation. Well, it's not linear, but still, so you can actually work out kind of how many lives do you save - disability-adjusted life years? Do you save for each point on the scale from that correlation? And then we see that those countries that have a higher GDP, and a higher GDP rate goes into healthcare do better. Which makes sense, of course. So that was taken as a strong sort of suggestion that, that the JEE that has actually been developed as part of the IHR and the IHR, whole point of the IHR is to create capabilities that would prevent, and to a certain extent protect us from the effects of pandemics. So that was the hypothesis at that time. Now, of course, we couldn't test that hypothesis, because there was there was no pandemic, but then we got COVID. So, we've been able to look at that. And what we see is that unfortunately, it doesn't hold up. So, there is no clear correlation between JEE scores or SPARs scores, even within Europe, with the hard outcome indicators, especially if you look at population death rates due to COVID, which is still maybe the most stable indicator. There are countries with high JEE scores that had quite a bad outcome, lots of deaths in relation to population, and then vice versa, the other way around. So, so that was a bit disappointing. And we're, of course thinking of reasons why it would be like that. 

Nick Harris 05:45

Yeah, so I guess that's sort of the next question is what that lack of correlation or a good outcome, what are the implications then from, from your point of view, for the JEEs and the SPARs as measurement systems?

Professor Mika Salminen 06:05

Yeah, I think I think the major problem with those early versions so especially, is that they are kind of geared towards the point where you still can prevent something, or prevent it becoming a big issue, or prevent it becoming a multi-country issue. And for those, those things, it's quite good those capabilities, which are measured there, because that's what what it's about to check. If you have the labs, you have the vaccine vaccination program, you have the surveillance system, you have the outbreak investigations, and so on. Those capabilities are enough for that. But then when you actually have completely new disease that takes over the entire world, it actually doesn't help. There's something else that you need. Placed in the in the European setting, the thing that failed was that our health systems were not resilient enough, which meant that they were in the brink of being overwhelmed. Which then meant that we had to do this quite draconian shutdowns of society, which are kind of, you know, medieval tactics. They're not what you would think that would happen in in a modern society. It's old school quarantine, it's very old school quarantine. And it was in no plans. I have not seen any plan in advance that actually thought about that. It was kind of considered impossible. So, so we need something else. And that's really what I would hope that the measurement instrument also would look much more rigorously into health system resilience. We have to develop it also. But if nobody looks at it, it doesn't happen by itself. And I'm already a bit pessimistic that countries have learned from this.

Nick Harris 08:15

Yeah. So, then you're talking about resilience. So, can you talk a little bit more about what that means? And then, and then also, how you see that applying, you know, we're trying to then measure that as well, it's obviously got implications for sure if we call it the JEE or some new form of that, but it's what's missing in the JEE, that would speak to your capabilities and preparedness around resilience.

Professor Mika Salminen 08:43

So, it all goes back, of course to what do you want to achieve? What is it actually that we're trying to do when we are faced with a pandemic? So, two things, I guess one was that we wanted to minimise mortality, morbidity, illness, and death. That is kind of hard because it's a new disease, we don't have any drugs, we don't have any vaccines so you can do that with them those tools. Then we want to make sure that the health system is not so overwhelmed that all other care is jeopardised because you put everything on COVID and that is where we could do something, we could build a stronger system. That would be and what I mean with resilience is that that you know, in the finished plans, we kind of expected that okay, we take take the people from other sectors of the health system, people doing other things, not the infectious disease management, and we put them on the infectious disease management. And that works, but only for a certain time, because all the other things start stacking up. So, what we would really need is to do something similar that they do in the defence forces, where the whole defence force is there, with the hope that they will never need it actually, unless you're aggressive, aggressive nation, I don't think Australia is, and Finland, certainly it's not so. So, it means that you have to have extra, because if you don't have extra, when the crisis hits, you're in trouble. So, I think we have been too efficient with the health systems. And, and that needs to change if we are serious about not wanting to, you know, repeat the same things with the next pandemic. And the amazing thing is that this was very, very expensive. And I'm not sure it would be more expensive actually, to invest a bit more in the health systems.

Nick Harris 11:11

Yeah, so we have to work out our level of redundancy that is what we need.

Professor Mika Salminen 11:17

Yes, redundancy and some sort of of surge capacity, which is not capitalising on other activities within the health system, be then that we have some sort of extra personnel who have some training that can be brought in from other sectors temporarily. Can we be a bit lax in what we usually require, for example, there are countries that did this, Denmark used people who were quickly trained to do testing and to the vaccination, they were not medical personnel, and they could very quickly then scale up that activity. In Finland, it's legally not possible. And, and unions are absolutely against it. And that is a very bad thing, you know, in a pandemic action. So, we could have used students to do this work. Instead, they they really capitalised on school health care, on dental care, to find the people who do the testing, and the tracing, and all kinds of tasks, which you really don't necessarily have to have a medical education.

Nick Harris 12:38

Okay, and so, in terms of then measuring that a future state that's more resilient. How do you see that then? Is that the sort of thing then that you would also be trying to measure in something in JEE? And how do you see the changes that would be required there?

Professor Mika Salminen 13:00

So, I think this is what they have tried to do, actually, in the latest version, there's a new version of JEE coming out, the SPAR already has something like this. To be honest, those tools are kind of crude. And we have too many tools. If you look at what the United Nations and just the health sector in the United Nations asks every member states to report on, I think there's there's 10s of different annual reporting forms and the evaluation systems in there. And we could we could we could do with less, but certainly, I mean, that that is an area which which we would need to invest in, in to looking at building also accountability and, and also selling it to the, to those decision makers, who we work for that we are prepared to pay for that, even if it would cost a little bit more. 

Nick Harris 14:04

Yeah. Okay. So, I guess that leaves us with the yeah, with a where to next? Is that a discussion that is purely a national one? Or is it a is an international one as well? And how do you see the balance of that and maybe it will play out?

Professor Mika Salminen 14:33

It has to of course go down to the national level because each country has their own health health system and it's differently organised so, so one size model will not fit all. You have to come up with same with with different solutions in different countries based on how your system works. But what I see missing the moment in the international discussion, maybe it hasn't started, but it should start soon. Is that, okay, so we had this pandemic, we did things that we didn't plan for. Are those things, the things that we will do next time? Or do we need to think of something better? I haven't seen that discussion, even start, that we still just talk about what is happening now. But we should start thinking of what can we do better to avoid closing down the whole whole globe if we have the risk of a pandemic. Or at least how can we make it much shorter so that doesn't shut down everything for two years, which has major, major consequences, not just for our economy, but for health and welfare also, especially in those countries, which are not that well off.

Nick Harris 15:53

And so, I guess, where do you see maybe in the, in the international space? Where do you see those conversations best happening? Are they like, early and when they're maybe a bit trickier? Are they, are they sort of academic conversations or are they actually in the multilateral space?

Professor Mika Salminen 16:15

They would, they would need to be taken up to, certainly the academic space needs to chip in because because they are independent, then they can they can be objective, in a different way than that, that governments can. Often sometimes they can be over optimistic, but but still, that it's a necessary part of it. But eventually, it needs to come up on the on the multilateral fora, in the United Nations. In also more on the, the whole of society for not just health, because the pandemic was not just to have health issues was a whole of society crisis.

Nick Harris 16:59

Yeah. And that sort of leads us in a little bit to, I'm going to ask one of my sort of pet questions or issues, I’m a vet and epidemiologist by training and for me, one of the interesting questions around the discussion now is the balance between prevention, preparedness or detection, and there's some grey around the definitions there and, and then response. So, I'm curious, maybe in just a very broad brushstrokes, what your senses is of the, the, where the concentration of conversation is, around those sort of three elements, as we're looking forward from the pandemic.

Professor Mika Salminen 17:48

So, I mean, it's quite obvious that, that before the pandemic, especially many countries did not have the basic, basic things in place in terms of preventive measures in terms of actually knowing what is happening, surveillance and, and monitoring. That's quite clear. Part of that has actually been remedied. We need to make sure that we still keep it, and we could broaden it so it's not just the COVID. Because COVID is just one disease among many others so, so that needs to needs to lead to a kind of permanent strengthening of these, these capabilities across the board in, in all countries basically, eventually. But I think there’s also the need, then to think hard about what we do when, when we have tried to prevent, but it didn't happen, it didn't work. And it's gonna happen again. I mean, it's I think it's over optimistic. If even if we pour lots of money into into those primitive tools that we have now that we can guarantee that there will not be another pandemic in the in the world. I think that would be naive. So, so we have to think also how to manage the pandemic when it happens.

Nick Harris 19:46

Well, thanks for taking time to talk to us really appreciate it. 

Professor Mika Salminen 19:50

Thanks. 

Nick Harris 19:54

You’ve been listening to Professor Mika Salminen from the Finnish Institute for Health and Welfare. We hope you enjoyed hearing from Professor Salminen on the importance of future proofing our health systems in preparation for the next pandemic. Contain This is produced by the Indo Pacific Centre for Health Security. You can follow us on Twitter and Facebook at CentreHealthSec. Please join us for our next episode, where we will bring you another highlight of the Global Health Security Conference in Singapore.