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Emergency health and humanitarian nonprofits work under volatile circumstances that strain nonprofits' financial resources. This study investigates the impact of revenue composition on the financial health of these nonprofits and the impact of financial health on the likelihood of financial distress.

A sample of 11,335 emergency nonprofits from 2003 to 2020 was obtained through form 990 data and studied through a difference generalized method of moments (GMM) approach for the impact of revenue composition on financial health. The impact of financial health on financial distress was studied through panel logistics regression.

Revenue diversification adversely affects the financial health of nonprofit emergency health and humanitarian organizations contrary to the implications of modern portfolio theory. The financial health of nonprofit emergency health and humanitarian organizations is persistent through the significant positive effect of lags in most cases.

The emergency health subsector of nonprofits was studied separately due to the unique nature of the sectors' operations and operating environment. The impact of revenue composition was investigated on key dimensions of financial health. Omitted variable bias, simultaneity and dynamic endogeneity were handled through difference GMM.

While epidemiological studies have linked economic hardship and financial difficulties with psychological distress and suicide, investigation of financial concerns among users of public mental health services has been limited. Moreover, empirical data regarding a relationship between financial difficulties and mental health symptoms are lacking. The purpose of this paper is to examine the prevalence of financial difficulties among patients attending community mental health clinics, and to examine the relationship between such difficulties and psychological distress and suicidality.

Participants attending three community mental health clinics in British Columbia, Canada provided demographic information, including annual income, and completed brief measures of personal financial management, psychological distress and suicidal behavior.

Although more than half of participants reported good-to-excellent ability to pay their bills on time, nearly half indicated poor long-range saving and financial planning. Lower annual income was directly related to suicidality. Financial management difficulties were associated with psychological distress, and were significantly related to suicidality after controlling for the effects of income and psychological distress.

The findings highlight the need for attention to distress and suicidality as potential sequelae of financial management difficulties, and carry implications for further research, clinical intervention and social policy. The findings confirm the need to address financial needs and money management abilities among users of public mental health services.

The coronavirus disease 2019 (COVID-19) pandemic has become a global humanitarian challenge. This scourge has impacted people from all walks of life as well as every economic sector and activity, from travel to automotives, hotels to banking, and supply chain to retail. The pandemic has affected not only physical and mental health but also financial health. Studies have examined the pandemic's economic impact, but very few have examined its impact on personal finances. Efforts to contain the pandemic's spread, such as lockdowns, have resulted in suspended business operations throughout the world that have intensified joblessness. To prepare and protect people from such unforeseen situations, financial education and planning are necessary. We attempt to expand the evidence on this issue by applying a structural equation modelling approach to identify the mediating role of financial literacy programs in preparing and protecting household wealth against sudden worldwide setbacks. The research design is descriptive and exploratory using snowball sampling technique. The data was collected through an internet survey. In total, 400 survey responses were obtained. After testing the measurement model for key validity dimensions, the hypothesised causal relationships are examined in several path models. The results indicated that coronavirus awareness exerts a direct or indirect influence on the financial health of individuals through financial literacy. We conclude that financial literacy has a full mediating effect on the personal finance of individuals during the COVID-19 pandemic. The findings not only contributed to the need and understanding of financial literacy but also have managerial implications. Financial literacy programs provide investment advice and suggestions which are actionable and also work to help individuals to come out stronger in terms of knowledge and skill set when the COVID-19 crisis passes.

The long-term financial stability of hospital systems represents a “grand challenge” in health care. New ownership forms, such as private equity (PE), promise to achieve better financial performance than nonprofit or for-profit systems. In this study, we compare two systems with many similarities, but radically different ownership structures, missions, governance, and merger and acquisition (M&A) strategies. Both were nonprofit, religious systems serving low-income communities – Montefiore Health System and Caritas Christi Health Care.

Montefiore's M&A strategy was to invest in local hospitals and create an integrated regional system, increasing revenues by adding primary doctors and community hospitals as feeders into the system and achieving efficiencies through effective resource allocation across specialized units. Slow and steady timing of acquisitions allowed for organizational learning and balancing of debt and equity. By 2019, it owned 11 hospitals with 40,000 employees and had strong positive financials and low reliance on debt.

By contrast, in 2010, PE firm Cerberus Capital bought out Caritas (renamed Steward Health Care System) and took control of the Board of Directors, who set the system's strategic direction. Cerberus used Steward as a platform for a massive debt-driven acquisition strategy. In 2016, it sold off most of its hospitals’ property for $1.25 billion, leaving hospitals saddled with long-term inflated leases; paid itself almost $500 million in dividends; and used the rest for leveraged buyouts of 27 hospitals in 9 states in 3 years. The rapid, scattershot M&A strategy was designed to create a large corporation that could be sold off in five years for financial gain – not for health care integration. Its debt load exploded, and by 2019, its financials were deeply in the red. Its Massachusetts hospitals were the worst financial performers of any system in the state. Cerberus exited Steward in 2020 in a deal that left its physicians, the new owners, holding the debt.

This study aims to examine the relationship between objective and subjective aspects of financial well-being, the role of family financial support and depression symptoms of Chinese older adults.

This study used two waves (2015 and 2018) of the Harmonized China Health and Retirement Longitudinal Study. Two financial ratios: the expenditure-to-income ratio and the financial assets ratio, were used to measure the objective aspect of financial well-being. Perceived money management difficulty was employed to measure the subjective aspect of financial well-being. Depression symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D) score. Three analytical models, including an ordinary least squares (OLS) model, an OLS model controlling for lagged depression and a random effects model using panel data, were used to examine the relationships between the objective and subject aspects of financial well-being and depression.

The results from the three models showed consistent relationships: the expenditure-to-income ratio was a positive contributor, while the financial assets ratio was a negative contributor to depression of older adults in China. The robustness check using binary-coded financial ratio thresholds showed that reaching the suggested thresholds was negatively associated with depression. Perceived money management difficulty contributed positively to depression. The robustness check using the fixed effects model showed no significance of the two ratios, while perceived money management difficulty was positively associated with depression. The insignificance might be due to data limitation (limited waves or rare changes across waves).

The findings indicate that both objective and subjective financial well-being matters in relation to depression symptoms and, therefore, to the overall mental health of the Chinese elderly. Developments in public policies are needed to promote accessible financial services, assistance programs, mental health services and facilities for the older population in China.

The overall objective of this research was to elucidate the ecosystem of women’s health social enterprises (WHSEs) based in the United States. The Aim I was to conduct a secondary data analysis of a random national sample of non-profit WHSEs based in the United States regarding their characteristics and areas of intervention. Aim II was to conduct a qualitative assessment of a sample of WHSEs based in the United States regarding their perspectives on the ecosystem of WHSEs. Aim I utilized the GuideStar database and assessed enterprise size, geographic location, financial distress, health intervention area, and health activity category using descriptive statistics, statistical tests, and multivariable regression analysis via SPSS. Aim II utilized in-depth interviewing and grounded theory analysis via MAXQDA 2018 to identify novel themes and core categories while using an established framework for mapping social enterprise ecosystems as a scaffold.

Aim I findings suggest that WHSE activity is more predominant in the south region of the United States but not geographically concentrated around cities previously identified as social enterprise hubs. WHSEs take a comprehensive approach to women’s health, often simultaneously focusing on multiple areas of health interventions. Although most WHSEs demonstrate a risk for financial distress, very few exhibited severe risk. Risk for financial distress was not significantly associated with any of the measured enterprise characteristics. Aim II generated four core categories of findings that describe the ecosystem of WHSE: (1) comprehensive, community-based, and culturally adaptive care; (2) interdependent innovation in systems, finances, and communication; (3) interdisciplinary, cross-enterprise collaboration; and (4) women’s health as the foundation for family and population health. These findings are consistent with the three-failures theory for non-profit organizations, particularly that WHSEs address government failure by focusing on the unmet women’s health needs of the underserved populations (in contrast to the supply of services supported by the median voter) and address the market failure of over exclusion through strategies such as cross-subsidization and price discrimination. While WHSEs operate with levels of financial risk and are subject to the voluntary sector failure of philanthropic insufficiency, the data also show that they act to remediate other threats of voluntary failure.

Aim I findings highlight the importance of understanding financial performance of WHSEs. Also, lack of significant associations between our assessed enterprise characteristics and their financial risk suggests need for additional research to identify factors that influence financial performance of WHSE. Aim II findings show that WHSEs are currently engaged in complex care coordination and comprehensive biopsychosocial care for women and their families, suggesting that these enterprises may serve as a model for improving women’s health and health care. The community-oriented and interdisciplinary nature of WHSE as highlighted by our study may also serve as a unique approach for research and education purposes. Additional research on the ecosystem of WHSE is needed in order to better inform generalizability of our findings and to elucidate how WHSE interventions may be integrated into policies and practices to improve women’s health.

The purpose of this research is to examine fiscal health of a specific local enterprise operation: seaports. Seaports provide unique local services while spending and borrowing billions of dollars. Decision makers should be aware of the fiscal health of these enterprises in part to assess the potential risks to the fiscal health of the government at large or public authority. Using eight stock and flow fiscal indicators appropriate for enterprise activities, this research examines eight seaports to compare fiscal health by geographic location and governing structure as well as the connection between long-term and short-term fiscal measures. Descriptive measures suggest that western and public authority ports exhibit better fiscal health than southern and departmental ports with some evidence showing a modest link between long-term and short-term fiscal health.

Objective – This chapter assesses the extent to which previous economic and financial crises had a negative impact on health outcomes and health financing. In addition, we review evidence related to the effectiveness of different policy measures undertaken in past crises to protect access to health services, especially for the poor and vulnerable. The current global crisis is unique both in terms of its scale and origins. Unlike most previous instances, the current crisis has its origins in developed countries, initially the United States, before it spread to middle- and lower-income countries. The current crisis is now affecting almost all countries at all levels of income. This chapter addresses several key questions aimed at helping inform possible policy responses to the current crisis from the perspective of the health sector: What is the nature of the current crisis and in what ways does it differ from previous experiences? What are some of the key lessons from previous crises? How have governments responded previously to protect health from such macroeconomic shocks? How can we improve the likelihood of positive action today?

Methodology/approach – The chapter reviews the literature on the impact of financial crises on health outcomes and health expenditures and on the effectiveness of past policy efforts to protect human development during periods of economic downturn. It also presents analysis of household surveys and health expenditure data to track health seeking behavior and out-of-pocket expenditures by households during times of financial crisis.

Findings – Evidence from previous crises indicates that health-related impacts during economic downturns can occur through various channels. The impact in households experiencing reductions in employment and income could be manifest in terms of poorer nutritional outcomes and lower levels of utilization of health care when needed. Households may become impoverished, reduce needed health services, and experience reductions in consumption as a result of health shocks occurring during a time when their economic vulnerability has increased. Women, children, the poor, and informal sector workers are likely to be most at risk of experiencing negative health-related consequences in a crisis. Real government spending per capita on health care could decline due to reduced revenues, currency devaluations, and potential reductions in external aid flows. Low-income countries with weak fiscal positions are likely to be the most vulnerable.

Implications for policy – Past crises can inform policy-making aimed at protecting health outcomes and reducing financial risk from health shocks. Evidence from previous crises indicates that broad-brush strategies that maintained overall levels of government health spending tended not to be successful, failing to protect access to quality health services especially for the poor. It is particularly vital to ensure access to essential health commodities, which in many low-income countries are imported, in the face of weakening exchange rates. Focused efforts to sustain the supply of lower-level basic services, combined with targeted demand-side approaches like conditional cash transfers may be more effective than broader sectoral approaches. Low-income countries may need specific short-term measures to ensure that health outcomes do not suffer.

Under the Patient Protection and Affordable Care Act (ACA), many low-income consumers have become eligible for government support to buy health insurance. Whether these consumers are able to take advantage of the support and to make sound decisions about purchasing health insurance likely depends on their knowledge and skills in navigating complex financial products. This ability is frequently referred to as “financial literacy.” We examined the level and distribution of consumers' financial literacy across income groups, using 2012 data collected in the RAND American Life Panel, an internet panel representative of the US population. Low financial literacy was particularly prevalent among individuals with incomes between 100% and 400% of the federal poverty level, many of whom will be eligible for health insurance subsidies. In this group, people who are young, less educated, female, and have less income were more likely to have low financial literacy. Our findings suggest the need for targeted policies to support vulnerable consumers in making good choices for themselves, possibly above and beyond the support measures already part of the ACA.

Amid increasing interest in how government regulation and market competition affect the cost and financial sustainability in health care sector, it remains unclear whether health care providers behave similarly to their counterparts in other industries. The goal of this chapter is to study the degree to which health care providers manipulate accruals in periods of financial difficulties caused, in part, by the rising costs of labor.

We collected the financial information of health care providers in 43 countries from 1984 to 2013 and conducted a pooled cross-sectional study with country and year fixed-effects.

The empirical evidence shows that health care providers with higher wage costs are more likely to smooth their earnings in order to maintain financial sustainability.

The finding of this study not only informs regulators that earnings management is pervasive in health care organizations around the world, but also contributes to the studies of financial book-tax reporting alignment, given the existing empirical evidence linking earnings management to corporate tax avoidance in this very sector.