O arcabouço institucional dos contratos de gestão nas parcerias com Organizações Sociais de Saúde no Estado de Goiás: um estudo de caso da Associação Goiana de Integralização e Reabilitação Agir

Abstract

This research aimed to analyze the institutional framework of partnerships between the State This research aimed to analyze the institutional framework of partnerships between the State of Goiás and social health organizations (OSS), established through management contracts, and their impacts on the efficiency, transparency, and accountability of public health policy. The study is based on the hypothesis that delegating the execution of public services to private entities, under the influence of New Public Management (NPM), has resulted in an informal privatization of the Unified Health System (SUS), marked by weak control mechanisms and deficient performance measurement. The main objective is to explain how and why these contracts changed the complementarity of health policy in Goiás, focusing on the actors involved and identifying the causal mechanisms underlying the adoption of the model and the institutional changes that have affected horizontal accountability. Methodologically, the research applies process tracing in a case study of Management Contract No. 123/2011, signed between the State Department of Health (SES) and the Goiana Association for Integration and Rehabilitation (AGIR), the managing organization of the State Rehabilitation Center (CRER).Data were collected through Freedom of Information requests (LAI) and document analysis from agencies such as the SES, the State Comptroller General's Office (CGE), the Court of Accounts (TCE), and the State Health Council (CES), integrating legal, economic, accounting, and institutional perspectives. The results show that management contracts do not detail direct or indirect costs, preventing an economic evaluation of efficiency. Performance goals are generic and disconnected from prior budgets or terms of reference, which contradicts the decision of the Federal Supreme Court (STF) in ADI No. 1.923/DF, which ruled that management contracts are legally equivalent to public agreements. The information asymmetry between the SES (principal) and the OSS (agents) generates risks of adverse selection and moral hazard, as explained by Agency Theory. At the same time, reporting mechanisms reduce rather than enhance transparency. The study also identified the capture of the model by interest groups, notably the Brazilian Institute of Social Health Organizations (IBROSS), which act to preserve the status quo, hindering oversight and the entry of new actors. Control bodies such as the TCE and CGE have reported irregularities, yet the partnership model remains neither questioned nor critically examined. The SES itself acknowledged the absence of technical studies demonstrating the model’s cost-effectiveness, reinforcing critiques regarding the lack of economic rationality. The study concludes that management contracts with OSS in Goiás operate within a fragile institutional arrangement, one that favors managerial autonomy at the expense of financial oversight and transparency. This dynamic distorts the principle of complementarity within the SUS, leading to a disguised form of privatization. The research recommends a review of the partnership model and contractual instruments, including the adoption of clear financial metrics aligned with STF guidelines on agreements, and the strengthening of mechanisms for social participation and external control