Infant, Neonatal, and Post-neonatal Mortality in Greece: A Nationwide Time-Trend Analysis.

INTRODUCTION: Infant mortality is a crucial perinatal measure and is also regarded as an important public health indicator. This study aimed to comprehensively present time trends in infant, neonatal, and post-neonatal mortality in Greece. METHODS: The annual infant mortality rate (IMR), the neonatal mortality rate (NMR), and the post-neonatal mortality rate (PNMR) were calculated based on official national data obtained from the Hellenic Statistical Authority, spanning 67 years from 1956 to 2022. The time trends of the mortality rates were evaluated using joinpoint regression analysis, and the annual percent changes (APC) and the overall average annual percent change (AAPC) were calculated with a 95% confidence interval (95% CI). RESULTS: The IMR exhibited accelerating declines over more than 50 years, with an APC of -1.9 (-2.8 to -1.0) from 1956 to 1968, -5.4 (-5.6 to -5.2) from 1968 to 1999, and -7.3 (-8.9 to -5.7) between 1999 and 2008. In 2008, IMR reached its all-time low of 2.7 per 1,000 live births, down 16.6-fold from its peak at 44.1 per 1,000 live births in 1957. This improving trend was reversed following the onset of the economic crisis in the country, leading to a 57% increase in IMR from 2008 to 2016, with an upward trend APC of 3.4 (1.2 to 5.5). In the recent period 2016-2022, there was an improvement with an APC of -3.7 (-6.2 to -1.1), resulting in an IMR of 3.1 per 1,000 live births in 2022. The decrease in IMR was estimated to have prevented 209,109 infant deaths in the country from 1958 to 2022. From 1956 to 2022, the IMR decreased with an AAPC of -3.9 (-4.3 to -3.4), while the PNMR saw a decline with an AAPC of -4.5 (-5.1 to -3.9) and the NMR with an AAPC of -3.2 (-3.7 to -2.6). CONCLUSION: Greece achieved an impressive decrease in infant mortality rates, but this progress was halted and completely reversed during the economic crisis. Although there have been some recent improvements after the country's economic recovery, the rates have yet to reach pre-crisis levels.

Impact of the economic crisis and drug shortage on Lebanese cancer patients' care.

BACKGROUND: As a consequence of the economic crisis, the sociopolitical instability and the advent of the coronavirus disease-19 pandemic, nested challenges faced the Lebanese healthcare system. These have resulted in critical shortages of essential resources, including medications vital for oncologic patients. AIM: To assess the ramifications of the ongoing economic crisis on oncology patient care focusing on our outpatient oncology department. METHODS: A questionnaire was distributed during the month of February 2022 to oncology patients in Hôtel Dieu de France University Hospital in Beirut during their outpatient therapy. The primary objective was to assess the far-reaching impact of the economic crisis on patient care and the resulting psychological implications. RESULTS: Among 182 interviewed patients, 31.87% experienced treatment interruption mainly due to acute drug shortages. Despite 87.91% of the patients benefiting from third-party coverage, 69.60% had to self-pay for their medications leading to 69.78% of patients perceiving that healthcare was more difficult to access after 2020. Psychologically, one-third of the patients exhibited symptoms of anxiety and/or depression, with 7 patients reporting suicidal ideations. Notably, 37.93% of patients who interrupted cancer treatment reported a history of comorbidities, and 89.66% who altered their treatment cited financial difficulties. CONCLUSION: Lebanese cancer patients face complex challenges spanning economic, healthcare, and psychological realms. Income inequalities exacerbated by the economic crisis hindered healthcare access.

Impact of the 2008 economic crisis on the burden of hepatitis B and C diseases in Southern European countries.

BACKGROUND: The economic crisis that began in 2008 has severely affected Southern (Greece, Italy, Portugal, Spain) Western European (SWE) countries of Western Europe (WE) and may have affected ongoing efforts to eliminate viral hepatitis. This study was conducted to investigate the impact of the economic crisis on the burden of HBV and HCV disease. METHODS: Global Burden of Diseases 2019 data were used to analyse the rates of epidemiological metrics of HBV and HCV acute and chronic infections in SWE and WE. Time series modelling was performed to quantify the impact of healthcare expenditure on the time trend of HBV and HCV disease burden in 2000-2019. RESULTS: Declining trends in incidence and prevalence rates of acute HBV (aHBV) and chronic HBV were observed in SWE and WE, with the pace of decline being slower in the post-austerity period (2010-2019) and mortality due to HBV stabilised in SWE. Acute HCV (aHCV) metrics and chronic HCV incidence and mortality showed a stable trend in SWE and WE, whereas the prevalence of chronic HCV showed an oscillating trend, decreasing in WE in 2010-2019 (p < 0.001). Liver cancer due to both hepatitis infections showed a stagnant burden over time. An inverse association was observed between health expenditure and metrics of both acute and chronic HBV and HCV. CONCLUSIONS: Epidemiological metrics for HBV and HCV showed a slower pace of decline in the post-austerity period with better improvement for HBV, a stabilisation of mortality and a stagnant burden for liver cancer due to both hepatitis infections. The economic crisis of 2008 had a negative impact on the burden of hepatitis B and C. Elimination of HBV and HCV by 2030 will be a major challenge in the SWE countries.

Providing Health Care and Social Support during Economic Crises: Lessons Learned from "Solidarity Outpatient Clinics" in Greece during the Great Recession.

"Solidarity outpatient clinics" (SOCs) emerged in Greece as a novel community-based health care resource during the global economic crisis that started in 2008. They have provided crucial social support to diverse vulnerable populations. Solidarity is a critical organizational principle underlying SOCs' operation. It is juxtaposed to charity to emphasize, among other things, building symmetrical relationships between providers and patients. Employing a case study approach and a multilevel, multimethod research design, we analyzed qualitative data collected through semistructured interviews (N = 20) with patients, staff, and other local stakeholders and content of monthly informational bulletins (N = 26) and weekly radio shows (N = 48) produced by a prominent SOC in Greece's capital. Findings provide insight into structural and functional dimensions of social support exchanges at SOCs and extend our understanding of different types of social support and the organizational contexts through which they are secured, particularly during financial crises.

Effectiveness of physical barriers to prevent suicide by jumping from high-risk bridges: From an integrative review to a northern Italian province's paradigm.

Background: Although uncommon, suicide by jumping is almost always lethal and can be significantly elevated locally due to the availability of tall structures including bridges and other high-risk locations. Empirical evidence suggests that restricting access to certain suicide methods is highly effective at preventing suicide, prompting the construction of physical barriers in many high-risk jumping locations. However, some have argued that these measures are too costly and only lead to method or location substitution. Objectives: To examine whether physical barriers are effective at preventing suicide by jumping or whether method or location substitution occur. Methods: An integrative review of the most representative literature. Results: Results clearly show that physical barriers are highly effective at preventing suicide by jumping with little to no method or location substitution occurring. Furthermore, their cost is far outweighed by the monetary benefits of averted suicides. Conclusions: Using the Italian pre-alpine/alpine areas as a paradigm, we argue that local topography and socioeconomic particularities led to significantly elevated rates of suicide in general, and of suicide by jumping from bridges in particular, especially among young adults who are more vulnerable to economic crises and show elevated susceptibility to impulsive acts, a known characteristic associated with suicide by jumping, which makes the issue even more topical and clinically relevant. As these finding are easily generalized to other territories with similar topographical and/or economic characteristics, we end with a call to action, urging local authorities to heed the scientific evidence and take the necessary steps to improve suicide prevention.

Dynamic spillover between crude oil, gold, and Chinese stock market sectors -analysis of spillovers during financial crisis data during the last two decades.

The present study investigates the presence of asymmetric return spillovers among crude oil futures, gold futures, and ten Chinese stock sector markets. Time-varying asymmetric spillovers between commodities and the 10 sectors are shown by utilizing the spillover index developed by Diebold and Yilmaz (2012, 2014). Our findings indicate that the industrial and discretionary consumer sectors generate and benefit the most from spillovers. Furthermore, it has been established that the basic materials sector exhibits a net positive impact on spillovers. In contrast, oil futures, gold futures, and other sectors demonstrate a net negative impact as recipients of spillovers. Moreover, the negative return spillovers outweigh the positive return spillovers. Our analysis spans from 2000 to 2023 to include various financial crises. The spillover effects of asymmetry are impacted by various factors, including the global financial crisis (GFC), the European sovereign debt crisis (ESDC), the decline in oil prices, and the outbreak of the COVID-19 pandemic. Including gold and oil in individual equity markets can benefit equity investors. Furthermore, implementing hedging strategies is susceptible to the global financial crisis, economic slowdown, oil price decline, and the recent COVID-19 pandemic. The oil futures exhibit the greatest hedging effectiveness during the COVID-19 spread. The findings indicate that gold exhibits comparable outcomes solely in the presence of positive spillover effects. At the same time, its performance reaches its peak during the recovery phase in the context of negative spillover effects.

Smoking Habits and Nicotine Dependence Among the General Lebanese Population Before and During Both the Economic Crisis and COVID-19 Pandemic.

Objective: Smoking habits have widely changed over time; however, they remain a well-known fashion that risks people's health. In addition, nicotine addiction depends on the interplay between several factors. Our study aimed to understand the smoking habits and nicotine dependence in the Lebanese population before (September 2019) and during (June 2020) the economic crisis and COVID-19 pandemic. Methods: This observational cross-sectional survey-based study included 1560 Lebanese individuals aged between 13 and 75 years old from June till October 2020. Data collection was performed through an electronic survey including patients' demographics and validated instruments to assess addiction to nicotine (CAGE, Four C's, Fagerström test, and Smoker's profile scores). Results: Out of 1560 participants, 794 (50.9%) were males. The mean age was 26.5 ± 11.69 years, and 67.8% were aged between 18 and 25 years old. We found that 865 (55.4%) participants were smokers. In addition, smoking cigarettes or vaping, significantly increased between September 2019 and June 2020. Our smoker group showed a high CAGE positivity (P < .001), marked compulsion (P < .001), and a considerable lack of self-control to surcease smoking (P < .001). Furthermore, the nicotine dependence score (NDS) increased with age (B = .166) and decreased with higher educational levels (B = -.219). Conclusion: During the economic crisis and the COVID-19 pandemic, the Lebanese population showed an increased prevalence of smoking, a high level of CAGE positivity, strong compulsion, and a significant lack of self-control when it came to quitting smoking. This strongly entails public health measures for smoking cessation through national awareness campaigns.

Post-traumatic stress, depression, and anxiety during the 2021 Myanmar conflict: a nationwide population-based survey.

Background: The UN warns that Myanmar faces the 'triple crises' of mass conflict, uncontrolled COVID-19, and economic collapse. Therefore, we aimed to assess the population mental health burden, healthcare needs, and the associated risk factors in Myanmar. Methods: We established a nationwide random sample and recruited 1038 adults via random digit dialling from July 3-Aug 9, 2021, during the ongoing conflict since Feb 1, 2021, and surge in SARS-CoV-2 infections. Probable post-traumatic stress disorder (PTSD) was assessed using the PTSD Checklist-Civilian Version. Probable depression and anxiety were assessed using the Patient Health Questionnaire-2 and the Generalized Anxiety Disorder-2. We calculated population attributable fractions for probable mental disorders using multivariable logistic regression models. Based on the mental health burden and healthcare-seeking patterns, we projected the need for mental health services. Findings: During the 'triple crises', a third of adults in Myanmar (34.9%, 95% CI 32.0-37.7) reported a probable mental disorder. Prevalence of probable PTSD, depression, and anxiety were 8.1% (6.6-9.7), 14.3% (12.0-16.6), and 22.2% (19.7-24.7), respectively. We estimated that up to 79.9% (43.8-97.9) of probable PTSD was attributable to political stress. This corresponds to 2.1 million (1.1-3.2 million) fewer adults with probable PTSD if political stress was removed from the population. The mental health burden could translate into roughly 5.9 million adults seeking mental health services. Interpretation: The mental health burden in Myanmar is substantial, and population mental health might only be restored when the three crises have ended. An accelerated peace process is critical to protecting Myanmar's population mental health. Funding: This research was supported the Research Grants Council of the Hong Kong Special Administrative Region, China (Project No. HKU 17606122) and the Michele Tansella Award.

Choosing and accessing COVID-19 treatment options: a qualitative study with patients, caregivers, and health care providers in Lebanon.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has strained healthcare systems globally, particularly in terms of access to medicines. Lebanon has been greatly affected by the pandemic, having faced concomitant financial and economic crises. The objective of the study was to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, and healthcare providers, with regards to their treatment decisions and accessibility to COVID-19 medicines. METHODS: For this qualitative study, we conducted 28 semi-structured interviews. We used purposive sampling to recruit participants with a diverse range of perspectives. The data collection phase spanned from August to November 2021 and was conducted virtually. After transcribing and translating the interviews, we employed thematic analysis to identify recurring themes and patterns. RESULTS: In total, 28 individuals participated in this study. Participants highlighted challenges owing to the COVID-19 pandemic and economic crisis. Accessing COVID-19 medicines posed major hurdles for physicians and patients, given limited availability, global shortages, local circumstances, community hoarding and stockpiling by pharmacies. Providers based treatment decisions on research, local and international practice guidelines, experiences and expert feedback. Patients sought information from social media, community members and physicians, as well as through word of mouth. Accessing medicines involved navigating the healthcare system, the black market, charities, personal networks and political parties and sourcing from abroad. The medicines were either free, subsidized or at inflated costs. CONCLUSIONS: This study highlights the diversity and complexity of factors influencing decision-making and accessing medicines during the COVID-19 pandemic in Lebanon. Future research should explore strategies for ensuring medicine access during crises, drawing insights from comparative studies across different countries.

Unveiling the unseen toll: exploring the impact of the Lebanese economic crisis on the health-seeking behaviors in a sample of patients with diabetes and hypertension.

BACKGROUND: Against the backdrop of Lebanon's escalating multifaceted crisis which resulted in medication shortages for chronic diseases and unaffordable healthcare services, the current study endeavors to shed light on a critical yet overlooked facet of the Lebanese economic crisis- its profound impact on the health-seeking behaviors of patients with hypertension and diabetes mellitus. METHODS: An exploratory cross-sectional study based on an online questionnaire was conducted on 156 adult Lebanese citizens diagnosed medically with either hypertension or diabetes. We gathered sociodemographic characteristics and healthcare-related challenges faced during the economic crisis. We also assessed stress levels using the Depression Anxiety Stress Scale (DASS-21). Descriptive and bivariate analyses were done using SPSS version 26. RESULTS: The mean age of the population was 49.8 ± 17.7 years old, 51.6% were females and 48.4% were males, 29.7% had diabetes, 51.3% had hypertension and 19.0% had both diseases. Among all, 84.2% reported dissatisfaction with the current healthcare system, 31.6% reported changing their physician mainly because of unaffordable consultation fees (66%) or immigration of the physician (32%). Of those with hypertension and/or diabetes, less than 20% reported finding all their prescribed medications and 47% either modified or discontinued their treatment without seeking medical advice. In case of drug shortage, patients relied on stocked reserves (26%), alternative/generic medications (10%) and external sources for medication procurement such as relatives living abroad (41.7%), outsourcing suppliers (19.9%), dispensaries (19.6%) and NGOs (20.3%). All participants reported a high stress level (5.03/7) with a mean total DASS-21 score of 38.7 ± 35.8 that were attributed to August 4th Beirut port explosion (81.0%), global pandemic (81%), unstable political conditions (90.5%), economic crisis (96.8%), medication shortage (91.8%) and inability to access healthcare (74.1%). Higher sub-scores for anxiety, depression and total stress were insignificantly noted in participants with both hypertension and diabetes (p > 0.05). CONCLUSION: Our findings explore how the economic crisis has taken its toll on almost all aspects of healthcare in a sample of patients with diabetes and hypertension in Lebanon. The drug shortage as well as disruptions in affordable healthcare access imposed several barriers to adequate adherence to treatment regimens and acted as important mental health stressors.

Future of medical research in Sri Lanka: amidst economic chaos.

Sri Lanka is facing an economic crisis and medical research is significantly affected at present with researchers facing many obstacles. Urgent remedial measures are required to overcome the current situation if medical research is to continue in Sri Lanka.

The impact of national and international financial crises on mental health and well-being: a systematic review.

BACKGROUND: Evidence suggests that financial crises and poor mental health are reciprocally related, but no systematic review has been conducted to synthesise the existing literature on the impact of national and international financial crises on population-level mental health and well-being. AIMS: The aim of this study was to systematically review the available literature on the global impact of financial crises on mental health and well-being outcomes. METHODS: After registration on PROSPERO, a systematic search was conducted in PsycINFO, MEDLINE, Wiley, and Web of Science for papers published until 21 November 2022. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, 98 papers were identified as meeting eligibility criteria. Included studies were assessed using the Mixed Methods Appraisal Tool (MMAT) and results were presented in a formal narrative synthesis. RESULTS: Our findings show that financial crises are significantly associated with well-being and occurrence of psychological conditions. Several socio-demographic, cultural, and country-specific characteristics played a crucial role in the prevention of population mental health decline in periods of financial crises. CONCLUSIONS: Based on the findings of this review, evidence-based recommendations were developed to guide the design of policy actions that protect population mental health during and after financial crises.

Substance use disorder in the context of the economic crisis, covid-19 pandemic and social unrest: a cross-sectional study across Beirut (2020-2021).

BACKGROUND: Substance use disorder (SUD) is related to the interplay of various factors. The primary objective of this study was to assess the variation in substance use (SU) among a set of Lebanese people undergoing treatment for SUD during the Lebanese economic crisis, COVID-19 pandemic, and Beirut Blast. METHODS: A cross-sectional study including Lebanese adults previously diagnosed with and being treated for SUD at the Skoun center was conducted. Data collection was done using a paper-based Arabic questionnaire tackling the economic crisis, the Covid-19 pandemic, and the Beirut Blast, as well as the following scores: APGAR, PHQ-9, GAD-7 and PCL-6. Data were analyzed using SPSS version 25.0 with P value<0.05 considered significant. A bivariate analysis was conducted to study the association between the use of substances and study variables and scores. RESULTS: The sample included 126 men and 10 women. Most participants had a stable consumption of illicit drugs (58.8%), alcohol (76.5%), prescription drugs (70.6%) and non-prescription drugs (89%). Additionally, most participants had concomitant mild or moderate depression (55.1%), mild or moderate anxiety (50.7%), and PTSD (61.8%). Factors found to significantly increase SU were economic distress, change in employment status, and decrease in working hours. PTSD was also identified as a risk factor for increased illicit drug and alcohol use. Furthermore, severe anxiety was found to be a risk factor for increased alcohol consumption. CONCLUSION: Most participants were able to maintain a stable pattern of SU despite the quadruple crisis in Lebanon highlighting the important role played by Lebanese Non-Governmental Organizations (NGOs) and efforts employed to control SUD.

Losses never sleep - The effect of tax loss offset on stock market returns during economic crises.

We analyze to what extent more generous tax loss offset regulations are associated with a weaker decline and stronger recovery of firm stock prices during economic crises. We argue that an unrestricted loss carryforward and, particularly, an unrestricted loss carryback provides firms with additional liquidity, which should lower the risk of bankruptcy and can be used for investment purposes. Our empirical findings document that (1) an unrestricted loss carryforward and an unrestricted loss carryback result in a weaker decline and more timely recovery of stock prices during the considered crises, (2) this effect is stronger in high-tax countries, and (3) this effect is also dependent upon pre-crisis profitability.

The combined effect of social pensions and cash transfers on child mortality: evaluating the last two decades in Brazil and projecting their mitigating effect during the global economic crisis.

Background: The world is currently experiencing multiple economic crises due to the COVID-19 pandemic, war in Ukraine, and inflation surge, which disproportionately affect children, especially in low- and middle-income countries (LMICs). We evaluated if the expansion of Social Assistance, represented by Social Pensions (SP) and Conditional Cash Transfers (CCT), could reduce infant and child mortality, and mitigate excess deaths among children in Brazil, one of the LMICs most affected by these economic crises. Methods: We conducted a retrospective impact evaluation in a cohort of Brazilian municipalities from 2004 to 2019 using multivariable fixed-effects negative binomial models, adjusted for relevant demographic, social, and economic factors, to estimate the effects of the SP and CCT on infant and child mortality. To verify the robustness of the results, we conducted several sensitivity and triangulation analyses, including difference-in-difference with propensity-score matching. These results were incorporated into dynamic microsimulation models to generate projections to 2030 of various economic crises and Social Assistance scenarios. Findings: Consolidated coverage of SP was associated with significant reductions in infant and child mortality rates, with a rate ratio (RR) of 0.843 (95% CI: 0.826-0.861) and 0.840 (95% CI: 0.824-0.856), respectively. Similarly, CCT consolidated coverages showed RRs of 0.868 (95% CI: 0.842-0.849) and 0.874 (95% CI: 0.850-0.899) for infant and child mortality, respectively. The higher the degree of poverty in the municipalities, the stronger the impact of CCT on reducing child mortality. Given the current economic crisis, a mitigation strategy that will increase the coverage of SP and CCT could avert 148,736 (95% CI: 127,148-170,706) child deaths up to 2030, compared with fiscal austerity measures. Interpretation: SP and CCT programs could strongly reduce child mortality in LMICs, and their expansion should be considered as an effective strategy to mitigate the impact of the current multiple global economic crises. Funding: Bill & Melinda Gates Foundation, Grant_Number:INV-027961. Medical Research Council(MRC-UKRI),Grant_Number:MC_PC_MR/T023678/1.

The Impact of Change Management in the Greek National Health System: A Quantitative Study.

INTRODUCTION:  Serious changes took place in Greece due to the economic crisis of 2008, which led to significant changes in Greece's health sector. The reforms and changes that were made to the National Health System (NHS) aimed to improve it, provide quality services to its users, and adapt it to Greece's new external environment. The aim of this study was to assess the management of these changes by the leadership of the NHS and to examine their effectiveness. MATERIAL AND METHODS: The survey was based on quantitative research methods, using a questionnaire as a research tool. The sample population comprised employees of a tertiary-care public hospital in northern Greece. RESULTS:  We recruited a sample size of 100 participants for the survey. The questionnaire's Cronbach's alpha was equal to 0.724. The overall change management was moderate, and Greece's NHS did not follow a specific change-management model that provided principles facilitating the success of the effort. The most serious problems identified by using the questionnaire were the following: the changes were not structured and clear, the management set unrealistic goals and objectives, the changes to the NHS were made without the appropriate financial support, and there is uncertainty about the future of health care in Greece. CONCLUSION: The present study showed that changes cannot be made randomly; rather, they require careful planning and organization. Further changes, continuous feedback, and development are required to improve the status of Greece's healthcare system.

Predictors of Unmet Healthcare Needs during Economic and Health Crisis in Greece.

(1) Background: The aim of this study was to identify predictors of the unmet healthcare needs during the financial and recent health crisis in Greece. (2) Methods: Time series analysis was performed for the years 2008 through 2022 using the Eurostat database. The dependent variable was the percentage of people who reported unmet need for medical care. Demographic, socioeconomic, and health data, as well as health expenditures, were used as independent variables. Correlation analysis and simple linear regression models were conducted to analyze the results. (3) Results: Unmet health needs in Greece increased from the start of the crisis until 2016, as a gradual de-escalation of the crisis was observed. However, in 2019 the country recorded the second highest level of unmet needs for medical care before the health crisis. Limitations in usual activities, reporting bad/very bad health status, being unemployed, and having low income increased the likelihood of unmet needs. Health expenditures (public or private) were also significant determinants of unmet healthcare needs. (4) Conclusions: The increased unmet health needs widen inequalities in health and healthcare access. Therefore, health policies should eliminate barriers which restrict the access to health and enhance healthcare services, developing conditions for citizens' well-being.

Evaluating the Financial Performances of the Publicly Held Healthcare Companies in Crisis Periods in Türkiye.

The purpose of this study was to evaluate the financial performances of the publicly held healthcare companies in crisis periods in Türkiye. The 2018 economic crisis and the COVID-19 pandemic crisis were included in the study as the crisis periods. We collected the financial data of the publicly held healthcare companies and calculated three liquidity, three turnover, three leverage and three profitability ratios through ratio analysis to use as financial performance indicators. We then conducted Wilcoxon signed-rank tests and we performed separate analyses for the 2018 economic crisis and the COVID-19 pandemic crisis. The results of the analyses showed that there were no statistically significant differences between the publicly held healthcare companies' liquidity, turnover, leverage, profitability ratios and thus their financial performances before the crises and after the crises. While the results are reassuring and give valuable insights to managers and policy makers to determine the areas that needs to be strengthened to be better prepared for possible future crises, our sample was limited. Therefore, this study presents an exploratory foundation for future studies which are needed to make a case for financial stability for the publicly held healthcare companies before and after the crisis periods.

Long-term impacts of an early childhood shock on human capital: Evidence from the 1999 economic crisis in Ecuador.

This paper provides evidence on the lasting effects of the 1999 economic crisis in Ecuador on human capital formation. We show for children born during the crisis that the negative repercussions are still observable more than 10 years after macroeconomic recovery. Taking advantage of micro-level data collected in 2012 and 2014, we assess long-term impacts on health and education. After controlling for age-in-months and survey effects as well as a linear birth year-cohort trend that varies by region, we find that after 12-16 years, the cohorts born during the recession report height-for-age Z-scores that are 0.003 standard deviations (SDs) lower for each month of exposure and have 0.002 fewer years of schooling per month exposed compared to the cohorts born outside the recession years. Children exposed to the entire crisis are 0.063 SDs smaller and have 0.042 years less of schooling. Girls have lower health outcomes than boys. Concomitantly, we show that selective childbearing or excess infant mortality are unlikely to drive our results. The persistence of the negative effects points to the existence of a poverty trap suggesting that policy interventions in response to (economic) crizes should be extended beyond macroeconomic recovery to counteract long-term, micro-level consequences.