Integrity Mechanisms in the Hiring of Third Parties by Social Health Organizations

Maria Eduarda Maiello Maistrello; Murilo Cesar Merloto

DOI: 10.22167/2675-6528-202603246

Article derived from a Course Conclusion Work (TCC), with content based on the student’s original work and adapted to the editorial format of the E&S Magazine with the support of the ResumeAI tool, an artificial intelligence solution developed by Instituto Pecege for textual synthesis and organization.

Summary

The expansion of social health organizations in Brazil consolidated a management model characterized by the decentralization of public service execution and the intensification of third-party contracting. In this context, the integrity mechanisms applied to the contracting of outsourced companies by social health organizations were analyzed, using two entities located in the states of Goiás and Santa Catarina as empirical objects. The research adopted a qualitative approach, with a multiple case study method, based on the documentary analysis of management contracts, internal regulations, integrity programs, codes of ethics, transparency portal data, and information on contracts and contractual amendments. The results showed that both organizations had formal compliance instruments, such as integrity programs and codes of conduct. However, they presented relevant limitations in the transparency of third-party contracting, in the publicity of contracts, and in the disclosure of audit results and internal investigations, revealing a mismatch between the formal structure and its effective operationalization. It was concluded that the effectiveness of partnerships between the State and social organizations depends not only on the formal existence of integrity programs but also on the concrete application of control, oversight, and transparency practices compatible with the management of public resources within the scope of the Unified Health System (SUS).

Keywords: Compliance; Management contracts; Social health organizations; Integrity programs; Public services.

1. Introduction

The organization of civil society in Brazil is traditionally divided into three distinct sectors. The first encompasses direct and indirect Public Administration, the second comprises private companies, and the third sector includes associations, foundations, and non-governmental organizations, characterized by their private, non-profit nature, but with the purpose of providing benefits to the community (Di Pietro, 2005; Oliveira and Romão, 2014).

In the Brazilian context, social organizations were formally instituted by Law nº 9,637, of 1998 (Brazil, 1998). This regulation aimed at the decentralization of state activities in the education, health, and culture sectors, through accreditation and the celebration of management contracts, with the subsequent transfer of public resources. This process must observe the constitutional principles of equality and efficiency (Costa, 2020).

In the public health sector, there is a growing decentralization of the management and operation of hospital and outpatient units throughout the country. In this model, the State assumes the role of regulator, while social organizations act as executors of services provided to the population (Barcelos, 2022). This phenomenon, sometimes referred to as “privatization in a broad sense” (Di Pietro, 2004), grants social organizations the management of significant volumes of public resources with a certain discretion, which includes the possibility of outsourcing core activities, such as hiring medical teams and diagnostic services.

This scenario, although it promotes agility in service delivery, raises critical questions about the transparency and control of public resources. The hiring of third parties by social organizations, despite involving public interest and being financed with state funds, does not follow the procedures of a public tender, being governed by the Civil Code (Lins, 2022). Such a distinction can lead to irregularities, such as acts of corruption, favoritism in the selection of companies, contract overpricing, and inefficient use of resources, causing damage to the Unified Health System (SUS) and its beneficiaries (Lopes and Toyoshima, 2013).

Given this scenario, the implementation of effective integrity policies and guidelines in the hiring of third parties is fundamental for social health organizations, which manage significant amounts of public resources. Such mechanisms are indispensable not only to prevent, detect, and resolve business-inherent risks, but also to ensure transparency to society regarding an essential service such as public health, especially after the enactment of the Anti-Corruption Law (Franco, 2020).

Specialized literature reinforces that the management of public resources by private entities demands consistent institutional arrangements to ensure traceability, regulatory compliance, and effective control (Slomski et al., 2022). Integrity programs act as strategic instruments in preventing administrative failures, mitigating risks, and protecting the public interest (Spinelli and Teixeira, 2024), guiding conduct and structuring internal processes through codes of conduct, prior due diligence, whistleblowing channels, audits, and training (Assi and Hanoff, 2018).

The effectiveness of these instruments, however, depends on the articulation between formal norms, governance committees, and continuous monitoring mechanisms, preventing them from assuming a merely declaratory character (Slomski et al., 2022). The Access to Information Law (Brazil, 2011) also requires social organizations to make documents available on transparency portals, underscoring the importance of publicity. Studies indicate that the absence of systematic disclosure of contracts and internal investigation results compromises the transparency and effectiveness of integrity programs (Adusei, 2018).

Despite the existence of legal frameworks and the growing adoption of integrity programs, literature and empirical evidence point to weaknesses in the oversight and control of management contracts, as well as in the transparency of outsourced contracting, which can compromise the efficiency of public management and institutional integrity (Albuquerque et al., 2015; Khosravi et al., 2024; Silva et al., 2025). The complexity and volume of resources involved require an in-depth analysis of integrity mechanisms to identify gaps and propose improvements.

In this context, this study analyzed the integrity mechanisms adopted in the contracting of third parties by social health organizations, considering the legal framework, federal transfers, agreements, and the observed administrative dynamics. It sought to understand how these entities structure their control and compliance instruments in the selection of private companies, given their importance for governance and for the execution of services within the SUS, identifying the main weaknesses, inconsistencies, and need for improvements, which may support future work on this topic.

2. Material and Methods

The present study was characterized as qualitative research, of an exploratory-descriptive nature, using the multiple case study strategy. It was based on bibliographic and documentary research, and analysis of internal and external secondary data. The objective was to deepen the proposed theme and obtain greater knowledge of the object of study (Marconi and Lakatos, 2017).

For the unit of analysis, two social health organizations were selected, one in Goiás and another in Santa Catarina. Both manage state public hospital units through management contracts. The research timeframe covered the period between 2020 and 2024, influenced by the author’s previous professional experience, which facilitated the delimitation of the object and access to the necessary information.

Initially, a comprehensive bibliographic research was conducted, analyzing books, scientific articles, and pertinent legislation on governance in the third sector, compliance, integrity programs, social organization management, and outsourcing of public health services. This stage was fundamental for the construction of the theoretical framework and to support the critical analysis.

Subsequently, documentary research of secondary data, internal and external, from social health organizations was carried out, structured in four stages. The first stage analyzed management contracts and addenda, focusing on healthcare goals and procedures for contracting outsourced services.

The second stage was dedicated to the collection and analysis of integrity programs, codes of conduct, ethics channels, partner selection regulations, and governance guidelines, available on the entities’ electronic addresses and transparency portals.

In the third stage, selection processes, requirements, quotes, and contracts signed with outsourced companies for core business services, such as specialized doctors and supply of hospital products, were collected and analyzed. Clauses on ethics, anti-corruption, contractual non-compliance, metrics, deductions, oversight, and auditing were verified.

The fourth stage involved researching external data, such as administrative and judicial processes, reports from regulatory and oversight bodies, and specialized media news. This data was collected from state transparency portals and state audit courts, addressing issues such as contractual non-compliance, fraud, corruption, money laundering, and illicit activities.

For the data analysis, the procedure was carried out separately for each social organization. The data were examined and transcribed into reports, comparing them with the literature. Subsequently, a SWOT matrix (Strengths, Weaknesses, Opportunities and Threats) was used to evaluate the effectiveness of the mechanisms for hiring outsourced companies and identify points for future improvements (Sarsby, 2016).

Finally, the comparative method was applied between the cases of Goiás and Santa Catarina. A comparative table was structured based on the categories extracted from the data, aiming to systematize the differences and similarities between the analyzed organizations, which aided in understanding the integrity mechanisms and identifying gaps.

In observance of ethical precepts and the obligation of secrecy, the names of the social organizations under examination were not explicitly mentioned. Direct references to the accessed documents were omitted to avoid the identification of the entities, ensuring data confidentiality.

3. Results and Discussion

The research revealed that social health organizations, despite having formal integrity mechanisms, face significant challenges in ensuring transparency and effective control over the contracting of outsourced companies. This study, by analyzing two entities in the states of Goiás and Santa Catarina, identified a notable mismatch between the existence of compliance instruments and their effective operationalization. The findings indicate that the mere formal adoption of integrity programs does not, in itself, ensure robust governance, due accountability, and the prevention of irregularities in the management of public resources within the scope of the Unified Health System (SUS).

The expansion of social organizations in the health sector has intensified the debate on management models in the public sector, especially regarding the supervision of contracts with third parties. This scenario, as pointed out by Albuquerque et al. (2015), frequently generates tensions between public and private interests, requiring solid integrity and governance structures. The management of public funds by private entities, even non-profit ones, demands consistent institutional arrangements to ensure traceability, regulatory compliance, and effective control, as emphasized by Slomski et al. (2022).

Specialized literature reinforces that integrity systems play a strategic role in preventing administrative failures, mitigating risks, and protecting the public interest, as evidenced by Spinelli and Teixeira (2024). Assi and Hanoff (2018) highlight that integrity programs, which include codes of conduct, due diligence, whistleblowing channels, audits, and training, are essential for guiding conduct and structuring internal processes. However, the effectiveness of these instruments depends on the articulation between formal rules, governance committees, and continuous monitoring mechanisms, to prevent them from becoming merely declarative (Slomski et al., 2022).

The legal framework, including the Access to Information Law (Brazil, 2011), imposes on social organizations the obligation of transparency, requiring the public disclosure of institutional and operational documents. Lins (2022) clarifies that the contracting of third parties by social organizations, although governed by private law, must follow the principles of public procurement, such as legality, impersonality, morality, publicity, efficiency, transparency, and competitiveness, given the public nature of the interest involved. Adusei (2018) warns that the absence of systematic disclosure of contracts and internal investigation results significantly limits the transparency and effectiveness of integrity programs.

State of Goiás

In the state of Goiás, the social organization studied manages an expressive volume of public resources, with the research focused on a hospital unit. State Law No. 20.489/2019 (Goiás, 2019) establishes the mandatory nature of integrity programs, whose parameters include conduct standards, code of ethics, integrity procedures for all “stakeholders”, periodic training, risk assessments, transparent accounting records, and widely publicized reporting channels. This legal framework provides a formal basis for integrity governance in the entity.

Management contracts and their addenda, signed between the public entity and the social organization, impose healthcare goals, performance indicators, transparency obligations, and accountability. Limits were identified for the outsourcing of activities, requiring adherence to the principles of legality, impersonality, morality, publicity, and efficiency. The social organization is also compelled to develop its own regulations for the purchase of goods and services, with disclosure on its website, for the selection and contracting of outsourced companies, as recommended by Costa (2020).

The analysis of the social organization’s internal data revealed the existence of a formalized integrity program through a code of ethics and conduct, which establishes general corporate governance guidelines applicable to the members of its boards and executive management. The presence of a “Chief Compliance Officer” (CCO) was verified, indicating the incorporation of a formal compliance structure in the entity’s governance, an aspect considered relevant for the implementation and monitoring of integrity programs, as highlighted by Spinelli and Teixeira (2024) and Assi and Hanoff (2018).

Regarding the hiring of outsourced companies, the Code of Ethics and Conduct presents principiological provisions, such as the guarantee of equal treatment and the prohibition of undue advantages. The purchasing and contracting regulation provides for an initial documentary “due diligence”, requiring CNPJ, social contract, partners’ documents, and regularity certificates. Mechanisms such as multiple quotations and digital platforms are adopted to foster competition, and the documentation of all stages of the procedure must be made available on the social organization’s website, according to Slomski et al. (2022) and Costa (2020).

Contracts with outsourced companies, analyzed between 2020 and 2024, have a twelve-month term, with the possibility of renewal, suggesting potentially long-lasting relationships that require continuous attention to transparency and “accountability” (Albuquerque et al., 2015). Clauses were identified regarding the outsourced company’s liability for losses and damages, fines of up to ten percent of the total contract value for non-compliance, and the possibility of early termination. Payment is conditional upon the presentation of updated tax and labor certificates, aligning with practices for preventing irregularities (Adusei, 2018).

Despite the formality, the anti-corruption clause, based on Law No. 12.846/2013 (Brazil, 2013), proved to be predominantly declaratory, lacking specific operational obligations and clear monitoring mechanisms and penalties. No clauses were identified that required the third party’s adherence to the social organization’s integrity program, general audits, implementation of its own program by the contractor, periodic training, or explicit reference to the whistleblowing channel for contractual irregularities, weakening the program’s effectiveness, according to Franco (2020).

The active transparency of the social organization presented significant gaps, with the absence of reports on service execution, invoices, and effective fulfillment of welfare goals on the transparency portal, which compromises the effectiveness of control mechanisms, as pointed out by Adusei (2018). Additionally, 613 diligences were registered due to documentary inconsistencies or questions about the nature of expenses in audits by the Goiás State Health Secretariat, evidencing fragilities in the documentary control of financial operations and risks in contracting suppliers and outsourced personnel.

The social organization of Goiás figures as a passive party in 15 civil judicial processes in the Court of Justice of the State of Goiás (Goiás, 2026a), totaling more than six million reais in case values, related to serious medical errors that resulted in permanent disabilities and deaths. Although there are no final and unappealable convictions, the recurrence of these demands suggests possible deficiencies in the supervision of outsourced healthcare activities. Additionally, investigations by the Comptroller General of the Union (CGU, 2025) point to diversions of public funds, with suspected fraud originating from the contracting of outsourced companies with generic contracts and without goals, linked to politicians and administrators of the entity itself.

State of Santa Catarina

In the state of Santa Catarina, the social organization also manages hospital units with significant public resources, with the research focused on a state hospital. The management contract with the Secretariat of State Health of Santa Catarina defines care goals, performance indicators, and funding rules for the execution of hospital services. Similar to the case in Goiás, the model allows the contracting of outsourced companies, as long as contractual norms and the social organization’s internal regulations are respected. However, unlike Goiás, there is no specific state law that mandates the implementation of integrity programs.

Despite the absence of legal obligation, the transparency portal of the Santa Catarina hospital unit presents an integrity program and a code of ethics and conduct, both dated July 2023 with provision for annual updates. The code structures a normative framework for the contracting of third parties, establishing price quotation and selection based on objective criteria, such as product quality, best value for money, experience, expertise, and credibility of service providers, in addition to preference for companies with an integrity program, aligning with the specialized literature of Costa (2020).

Santa Catarina’s integrity program provides for the constant review of contracts and prohibits favoring one company over another, in line with Lins (2022) and the precepts of Bidding Law No. 14.133/2021 (Brazil, 2021). The existence of a compliance committee and a whistleblowing channel with specific instances for investigating irregularities and protecting the communicator demonstrates a guiding function of internal conduct and institutional alignment with the public purposes of health. The Compliance Committee is responsible for verifying reports and irregularities, mitigating risks of administrative discretion (Assi and Hanoff, 2018).

Despite the institutional mention of the publication of notices and quotations for the selection of suppliers, it was not possible to locate this information clearly, systematically, and accessibly in the digital environments of the entity or the Santa Catarina Health Secretariat (Santa Catarina, 2026). The electronic page indicated as a repository of information, notably the area intended for transparency and disclosure of call for tenders, was unavailable or offline during data collection, preventing access to the content that should have been published. This unavailability indicates a lack of publicity for outsourced selection processes.

Contracts with outsourced companies were not found on the social organization’s portal or the Santa Catarina Health Department’s portal during the entire research period, which compromises the verification of the entity’s integrity. Annual reports on the management contract execution indicate that outsourcing constitutes a structural element of hospital management, focusing on meeting healthcare goals and quality indicators. However, an opinion from January 2022 by the Health Department deemed the accounts irregular due to the absence of presentation of third-party contracts, resulting in the return of 789 thousand reais.

The social organization of Santa Catarina is under investigation by the Federal Police and the General Comptroller’s Office of the Union due to indications of embezzlement, money laundering, and criminal organization, substantiated by over-invoiced contracts and partners linked to the entity itself (CGU, 2025). This investigation led to the initiation of an administrative process to disqualify the social organization, which could result in the termination of all management contracts. Furthermore, nine judicial proceedings for medical malpractice in the Santa Catarina Court of Justice (Santa Catarina, 2025), totaling over four million reais, indicate flaws in the integrity of contracting and continuous oversight.

Comparative analysis between social organizations

The comparative analysis revealed that both social organizations have formal governance instruments and integrity programs, but with differences in institutionalization and similarities in implementation fragilities. Goiás stands out for the legal obligation of the integrity program, imposed by Law No. 20.489/2019, while in Santa Catarina the adoption is voluntary. Paradoxically, Santa Catarina’s program appears more structured in terms of a whistleblowing channel with whistleblower protection, a compliance committee, and training, suggesting that the absence of legal imposition does not prevent the adoption of best practices.

However, the effectiveness of integrity mechanisms converges on fragilities in both states. In Goiás, deficiencies include the absence of audits in outsourced companies, the non-adherence of contractors to the entity’s integrity program, limited “due diligence”, and the merely declaratory nature of anti-corruption clauses. In Santa Catarina, the main gap lies in the lack of transparency, evidenced by the unavailability of portals, the absence of publication of selection processes and contracts, and the existence of accounts judged irregular, with reimbursement of amounts.

Regarding the management of outsourced hiring, Goiás presents greater contractual detail, with provisions for deductions, penalties, and requirements for fiscal regularity, indicating a more structured formal control. In contrast, Santa Catarina, despite a structured integrity program, demonstrates a notable absence of publicity for selection processes and contracts, which is configured as a central indicator of fragility in the integrity of public procurement, underscoring the importance of active transparency in public resource management.

The analysis of control and oversight mechanisms also revealed differences. In Goiás, audit reports with a high number of inquiries demonstrate the action of state control, despite the organization’s internal fragilities. In Santa Catarina, the rejection of accounts by public administration, due to the absence of contracts with third parties and the consequent return of 789 thousand reais, points to a more critical failure in accountability. Both states face significant threats, such as lawsuits for medical malpractice and investigations for embezzlement of public funds.

Despite the observed distinctions, a central common point emerged from the comparative analysis: the outsourcing of the core activity, when associated with insufficient control mechanisms, represents the main institutional risk. The formal existence of integrity programs, by itself, is not sufficient to guarantee the integrity of contracts, requiring effective instruments for monitoring, transparency, and “accountability”. These results confirm the literature that points to the need for integration between formal norms and the effective operationalization of governance mechanisms to prevent irregularities (Khosravi et al., 2024; Silva et al., 2025).

The findings of this study evidenced that, although the analyzed social organizations possess a relevant degree of formal institutionalization of integrity mechanisms, the practical effectiveness of these instruments is compromised by significant gaps in transparency and control of third-party contracting. The limited public disclosure of contracts, the absence of robust audits, and the fragility in accountability indicate a mismatch between the formal structure and its operationalization. Such a scenario highlights the need to strengthen governance, continuous monitoring, and active transparency to ensure integrity in the execution of management contracts in the health sector and respond to the study’s objective.

4. Conclusion

This study analyzed the integrity mechanisms applied to the contracting of outsourced companies by social health organizations, seeking to understand the structuring of their control and compliance instruments. It was found that the investigated entities, located in the states of Goiás and Santa Catarina, formally possessed integrity programs, codes of ethics, and internal regulations. However, a disconnect was observed between the existence of these instruments and their effective operationalization. Significant limitations were identified in the active transparency of third-party contracting, in the publicity of contracts, and in the disclosure of audit results and internal investigations, which compromised the traceability and social control of public resources.

The main contribution of the work lies in demonstrating that the effectiveness of partnerships between the State and social health organizations is not limited to the formalization of integrity programs, but requires the concrete application of robust control, oversight, and transparency practices, compatible with the management of public resources within the scope of the Unified Health System. As a limitation, the multiple case study approach is highlighted, restricted to two social organizations and the analysis of public documentary sources, which prevents the generalization of results to all entities in the sector. For future studies, it is suggested to expand the analysis to social organizations in other states and to conduct empirical research with interviews of managers and control bodies, aiming to deepen the understanding of challenges and propose continuous improvements in compliance programs, strengthening governance and accountability in public health.

Bibliographic References

Adusei, C. 2018. Public procurement in the health services: application, compliance and challenges. Humanities and Social Sciences Letters 6(2), 41–50. Disponível em: <https://doi.org/

Assi, M; Hanoff, R. V. 2018. Compliance: Como implementar. Trevisan Editora, São Paulo, SP, Brasil.

Barcelos, C. O. G.; Andrade, M. V.; de Almeida Botega; L., & Malik, A. M. 2022. Censo das organizações sociais de saúde brasileiras: levantamento e caracterização. Jornal Brasileiro de Economia da Saúde. Disponível em: <https://jbes.com.br/index.php/jbes/article/view/94>. Acesso em: 23 out. 2025.

Brasil. 1998. Lei nº 9.637, de 15 de maio de 1998. Diário Oficial da União. Brasília, 18 de maio de 1998. Seção 1, p. 8.

Brasil. 2011. Lei nº 12.527, de 22 de maio de 2011. Goiânia, 6 de junho de 2013. Seção 1, p. 1.

Costa, J. M. F. 2020. Organizações Sociais: Lei 9.637/1998. 2ed. Thomson Reuters, São Paulo, SP, Brasil.

Di Pietro, M. S .Z. 2005. Direito Administrativo. 16ed. Atlas, São Paulo, SP, Brasil.

Di Pietro, M. S. Z. 2004. Parcerias na Administração Pública. 4ed. Atlas, São Paulo, SP, Brasil.

Franco, I. 2020. Background Check: Melhores práticas. p. 175-191. In: Salles, L. E; Santos, S. C; Silveira, L. D. O. S. Guia Prático de Compliance. Forense, Rio de Janeiro, RJ, Brasil.

Lins, B. W. 2022. Organizações Sociais e Contratos de Gestão. 3ed. Lumen Juris, Rio de Janeiro, RJ, Brasil.

Lopes, L. S.; Toyoshima, S. H. 2013. Evidências do impacto da corrupção sobre a eficiência das políticas de saúde e educação nos estados brasileiros. Planejamento e Políticas Públicas (41): 199-228. Disponível em: <https://www.ipea.gov.br/ppp/index.php/PPP/article/view/265>. Acesso em: 21 fev. 2026.

Oliveira, A.; Romão, V. 2014. Manual do Terceiro Setor e Instituições Religiosas. 4ed. Atlas, São Paulo, SP, Brasil.

Slomski, V. G.; de Britto, A. A.; Slomski, V.; de Souza Vasconcelos, A. L. F.; Lugoboni, L. F.; Imoniana, J. O. 2022. Compliance of management practices instituted in the third sector based on governance guidelines established by Brazilian organizations. Sustainability 14(9): 5366.

Spinelli, M. V. C.; Teixeira, M. A. C. 2024. A estruturação de sistemas de integridade como política pública. Cadernos da Escola Paulista de Contas Públicas, 1 Sem. 2024, p. 66.

Article originating from the Final Course Work of the Specialization in Compliance and ESG of the MBA USP/Esalq

To learn more about the course, click here and access the MBX Academy platform