Executive Summary

^{Author: Eduardo Henrique Briciug Martinez — Advisor: Andreza Maria Luzia Baldo De Souza}

^{Summary prepared by the ResumeAI tool, an artificial intelligence solution developed by the Pecege Institute focused on synthesis and writing.}

This study evaluates the economic-financial situation of six large non-profit hospitals in São Paulo, analyzing liquidity, profitability, and operational performance between 2019 and 2024. The analysis highlights the sustainability of these entities in a scenario of sectoral pressures, providing a diagnosis to support strategic decisions and public policies. The research’s relevance is grounded in the importance of philanthropic institutions for the Unified Health System (SUS), responsible for a significant portion of high-complexity treatments (MS, 2023). The COVID-19 pandemic imposed challenges on health systems (WHO, 2020), exacerbating fragilities and creating a new operational and financial environment.

Even before the pandemic, philanthropic hospitals were already facing economic and managerial fragility (Portela et al., 2004). Accounting for 37.6% of SUS hospitalizations in 2000, these entities operate in a complex ecosystem, depending on government transfers and donations, which demands transparency in their accounts (Milani Filho, 2013). The post-pandemic period intensified these pressures with new variables such as the increase in litigation in supplementary health (Wang et al., 2025), interest rate volatility (BACEN, 2025a) and exchange rates (BACEN, 2025b), and the growth of operational costs, driven by population aging (SEADE, 2022) and the expansion of mandatory coverage (ANS, 2021).

Hospital management is a highly complex activity, demanding competencies to navigate regulatory and operational systems (Farias and Araujo, 2017). Innovations, escalating costs, and regulatory demands increase the challenge (La Forgia and Couttolenc, 2009; Spanos et al., 2024). In this scenario, the analysis of financial statements is essential to diagnose the condition of healthcare organizations (Assaf Neto, 2023). The central question is to identify the economic-financial conditions of philanthropic hospitals in São Paulo after the pandemic.

The research is justified by the need to understand the resilience and adaptation of these vital institutions. The analysis of the historical series (2019-2024) offers a longitudinal view of performance trends. The comparison with private sector benchmarks, such as the data from the Assaf Institute (2025) and the standard indices of Lira et al. (2021), positions the performance of philanthropic entities within the market context, evaluating whether their trajectories follow sectoral patterns.

The work contributes with a robust quantitative analysis of a frequently discussed but little analyzed segment with financial rigor. The findings can inform managers about vulnerabilities and subsidize public policies for the review of financing models. The analysis of liquidity, profitability, indebtedness, and operational efficiency indicators allows for a multifaceted understanding of financial health.

The methodology is a quantitative exploratory research, with a non-probabilistic design based on multiple cases. The sample was intentional, focused on six large philanthropic institutions in São Paulo, with publicly accessible financial information. The choice prioritized entities in the Paulista Macrometropolis (Demanboro et al., 2019), with four in the Metropolitan Region of São Paulo and two in the interior. The sample included three Santas Casas de Misericórdia with more than 200 beds. Data collection used secondary sources, such as Activity Reports, Income Statements, and Balance Sheets.

The data treatment focused on three axes of financial analysis (Matarazzo, 2008; Marion, 2010): liquidity, profitability, and capital structure. The analysis period, from 2019 to 2024, used 2019 as a pre-pandemic baseline to assess the impact of the health crisis, which distorted results in 2020 and 2021. The selection of indicators followed Matarazzo (2008), using a concise set: Current Liquidity (CL), Net Margin (NM), Return on Equity (ROE), EBITDA Margin, Total Debt (TD), Equity Immobilization (EI), and Result per Bed.

In the collection, the absence of inventory accounts in one-third of the entities made the calculation of Quick Ratio unfeasible, a limitation also observed by Barbosa et al. (2021), reinforcing the focus on indicators with consistently available data. The analysis of the results was structured in three stages: descriptive presentation of the evolution of indicators; comparison with the standard indices of private hospitals by Lira et al. (2021); and application of statistical tests to compare the sample means with data from the Medical and Hospital Services segment of Instituto Assaf (2025).

For the statistical analysis, the Shapiro-Wilk normality test was applied to the annual averages of the indicators (Favero and Belfiore, 2025). Subsequently, the independent samples t-test was used for indicators with normal distribution to verify if the differences between the sample averages and the market averages were statistically significant (Larson and Farber, 2010). The research was exempted from submission to the Research Ethics Committee (Resolution CNS No. 510/2016) as it only used public data.

Liquidity indicators revealed resilience, but with warning signs. Current Ratio (CR) showed an average of 1.67 in 2019, falling to 1.39 in 2023, but remaining above 1.0. The result indicates that institutions, on average, had a buffer to honor immediate commitments, but the downward trend suggests deterioration. The comparison with Instituto Assaf (2025) showed behavior similar to the market, although the philanthropic recovery in 2024 was more modest. Entity “D” was concerning, with CR consistently below 0.5, signaling a severe risk of insolvency (Batrancea, 2021).

Profitability indicators showed high volatility and a deteriorating trend. Net Margin (NM) fluctuated, with negative results for some entities between 2020 and 2022. The average was distorted by exceptional results from entity “D”, but the median revealed a drop from 5.14% in 2019 to 2.4% in 2024. This reduction of over 50% signals pressure on margins. Return on Equity (ROE) followed a similar trajectory. Although the sample average closed 2024 at 5.25%, above the market sector (2.84%), performance was driven by a few entities, with a general downward trend. The recurring decline in profitability may indicate structural deterioration, requiring prudent management of the capital structure (Dueñas Casallas et al., 2025).

The EBITDA Margin, despite methodological caveats (Madaleno et al., 2022), showed a slightly negative trend for the sample, contrasting with the stability in ANAHP (2025) data for the private sector. The Return on Assets (ROA) also showed a decline in 2020 and 2021, with a slight subsequent recovery, but without returning to 2019 levels. The joint decreasing trend of ROA and CL is concerning, as ROA influences current liquidity (Batrancea, 2021), suggesting that lower efficiency in profit generation may be contributing to liquidity tightening.

The capital structure revealed high indebtedness. Total Indebtedness (TI) showed that, at the median, the indicator remained stable, but at levels above the safety range of 30% (Batrancea, 2021). Three of the six entities (“A”, “B”, and “C”) presented an upward trend in indebtedness, reaching their highest levels in 2023 and 2024, representing a risk to the perpetuity of the business. The Immobilization of Net Equity (INE) indicated that the entities applied a considerable portion of their own resources to permanent assets, which may increase dependence on third-party capital for working capital (Souza et al., 2009). However, compared to the benchmark index of Lira et al. (2021), the São Paulo hospitals presented a relatively positive result.

The Result per Bed, an indicator of operational efficiency, had its best average performance in 2021, after a 2020 with a negative average. The comparison with previous studies (Souza et al., 2014; Bem et al., 2014) suggests that the entities in the sample operate in a relatively low profitability range per bed. While international studies identify an optimal point of efficiency in intermediate and high revenue ranges, the analyzed institutions did not reach these levels, reinforcing the need for process improvement to increase profitability.

Horizontal analysis confirmed the trends, showing that the total liabilities of the entities grew by 83.4% between 2019 and 2024, an increase higher than that of total assets (65.3%) and the inflation for the period (33.47%), evidencing the growing indebtedness. Net operating revenue grew by 65.0%, surpassing inflation, which indicates the capacity to pass on costs or an increase in volume, but which did not translate into improved profitability, as seen in the Net Margin.

The contextualization of the pandemic period deepens the discussion. Between March 2020 and June 2022, the suspension of SUS (Brazil, 2020) targets ensured revenue stability, which may have masked operational difficulties. In parallel, health insurance operators recorded record results in 2020 and 2021 due to the reduction in elective procedures, reverting to losses in 2022 and only returning to 2019 levels in early 2025 (ANS, 2025). This sectoral dynamic influenced the financial environment of the entities.

The application of Student’s t-test, comparing the means of the sample indicators with those of the market (Instituto Assaf, 2025), found no statistically relevant differences at the 95% confidence level. This significant finding suggests that the pressures in the health sector during the period occurred homogeneously, affecting both non-profit entities and publicly traded companies. The conclusion aligns with Veloso and Malik (2010), who also identified no substantial differences in economic-financial performance between hospitals of different legal natures, indicating that all organizations react similarly to market pressures.

The economic-financial assessment of philanthropic hospitals in São Paulo in the post-pandemic period reveals short-term resilience (current liquidity > 1.0), but with worrying structural fragilities. The drop in profitability, high and growing indebtedness, and modest operational efficiency constitute risks to the sustainability of the model. The absence of statistical differences compared to the market sector suggests that these entities are exposed to the same systemic pressures, but with less flexibility to react. The continuity of their operations will depend on advances in management efficiency and the restructuring of financing models.

The study’s limitations include the delay in making 2024 data available and the lack of accounting standardization, which prevented the analysis of operational cycle indicators. Nevertheless, the results provide a robust diagnosis and a warning. Based on the foregoing, it is concluded that the work’s objective was achieved, by evaluating the economic-financial situation of hospitals and identifying their vulnerabilities in the post-pandemic scenario. It is suggested that future research explore the impact of new technologies, such as artificial intelligence and telemedicine, on the economic efficiency of these entities, and the influence of SUS remuneration tables on their financial cycles.

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Executive summary from the Final Project of the Specialization in Finance and Controllership of the MBA USP/Esalq

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