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The financialization of healthcare

An evaluation of the Brazilian healthcare plans (2007–2019)
La financiarisation des soins de santé : Une évaluation des plans de santé brésiliens (2007-2019)
La financiarización de la sanidad: Una evaluación de los planes sanitarios brasileños (2007-2019)
Norberto Montani Martins et Carlos Ocké-Reis


Dans le capitalisme contemporain, la finance a étendu son champ d'action à toujours plus de secteurs économiques traditionnellement associés à la fourniture de services publics ou à la politique sociale, les soins de santé apparaissant comme un domaine de premier plan où le capital fictif a pu prospérer. La financiarisation exerce une influence directe sur la prestation des services de santé publique tout en remodelant le comportement et les opérations des prestataires de soins de santé privés comme des compagnies d'assurance maladie. Cet article vise à caractériser le processus de financiarisation des soins de santé au Brésil en analysant le comportement des entreprises du marché de l'assurance maladie privée entre 2007 et 2019. Ces entreprises assurent une couverture des soins de santé parallèlement au système de santé unifié (SUS), ce qui constitue un moyen d'accumulation de capital. L'article analyse comment les stratégies de gestion de l'actif, du passif et des capitaux propres des entreprises leaders intervenant sur le marché des entreprises privées d'assurance maladie, telles qu'elles sont exprimées par les mouvements enregistrés dans leurs bilans, nous éclairent sur leur processus de financiarisation. Un ensemble d'indices de financiarisation est mis au point, portant sur : (i) la financiarisation de l'actif, (ii) la financiarisation du passif et (iii) la maximisation de la valeur actionnariale. Les données économico-financières et les états financiers mis à disposition par l'Agence brésilienne de régulation de l'assurance maladie privée (ANS) sont mobilisés pour construire ces indices. Les résultats révèlent que les entreprises leaders consacrent une part importante de leurs ressources aux actifs financiers, alors que le poids des gains financiers dans les bénéfices globaux est faible. En ce qui concerne l'endettement, les résultats ne montrent pas d'augmentation de l'effet de levier et de la charge financière, ni ne confirment l'hypothèse d'une sensibilité accrue à l'influence des créanciers. Enfin, les modifications de la structure des capitaux propres et les introductions en bourse suggèrent que les pratiques de gestion tendent à s'aligner sur les normes de gouvernance pratiquées sur les marchés de capitaux. En conclusion, nous estimons que ces entreprises font, de manière croissante, office de plateformes pour l'accumulation financière par d'autres agents économiques et nous établissons un programme de recherche sur la question.

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  • 1 According to Palludeto and Rossi (2022, p. 551): “Fictitious capital can be understood as capital (...)

1Financial dominance has become one of the central features of capitalism at the turn of the 20th to the 21st century (Braga et al., 2017). This process, also known as financialization, marks a new stage in the development of capitalism, in which fictitious capital increases its scope and prevalence in the accumulation of capital.1 This dominance refers not only to the intensive expansion of fictitious capital, which is reflected in financial booms such as the one that preceded the 2008 Global Financial Crisis, but also to a process of extensive expansion, through which fictitious capital attaches itself “to new activities from which it was previously absent or even absented by virtue of regulation or a form of provision” (Fine, 2013, p. 55).

2The literature on financialization is full of examples of how financial dominance embraced an increasing number of activities that are commonly associated with public provision or some form of social policy: social assistance, pensions, education, housing, urban infrastructure and healthcare (Lavinas, 2017; Mader, Mertens & Zwan, 2020). The relationship of financialization and public health systems is well-documented (Cordilha, 2022), though the impact of such process also influences private health systems, changing the way private healthcare providers, health insurance firms, and hospitals, among others, behave and operate. Hunter & Murray (2019, p. 1271) describe the process of financialization in healthcare as a process that transforms “population ill-health into zones for investment” and creates “saleable commodities that can be traded by domestic and transnational private capital”.

  • 2 According to the World Health Organization (2023): “Universal health coverage (UHC) means that all (...)

3In Brazil, the healthcare system underwent significant changes in the last decades. The Unified Health System (Sistema Único de Saúde [SUS]) was created in 1988, aiming to provide universal health to hundreds of millions of Brazilians citizens, being the largest universal system in terms of population coverage in the world (Cordilha, 2023, p. 181).2 Paradoxically, the creation of SUS did not shrink the provision of private healthcare; on the contrary, the private sector expanded as well, barely doubling its coverage, reaching nowadays circa 50 million people according to data of the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar [ANS]).

  • 3 For a description of the Brazilian health system, see Ferreira (2022) and Cordilha (2023, 176-196)

4In that sense, Brazil developed a model of social protection for health that was marked by the parallel–sometimes duplicate–provision by the State and the market (Bahia, 2009; Ocké-Reis, 2009).3 Over time, resources allocated to SUS over the GDP have remained stable, while households and employers’ spending on health plans has increased substantially, sponsored by tax subsidies, favoring the commodification of the sector (Lavinas & Gentil, 2018; Ocké-Reis, 2018). This balance between public and private healthcare provision tilted even further after the adoption of a Draconian fiscal rule in 2016, which imposed a ceiling on primary government expenditures and reduced the (real) federal expenditure floor on healthcare–an alarming scenario especially if we consider that this period was just before the Covid-19 pandemic (Moretti, Funcia & Ocké-Reis, 2020).

5The dynamics of capitalist accumulation in that period reflected the advance of the financialization process in the Brazilian society (Lavinas, 2017; Lavinas, Araújo & Bruno, 2019). A growing body of literature, taking various approaches, has argued that healthcare provision in Brazil is characterized by an intensive and extensive process of financialization (Bahia et al., 2016; Sestelo et al., 2017; Lavinas & Gentil, 2018; Sestelo, 2018a; 2018b; Ferreira, 2022; Cordilha, 2023). This process is in line with global trends toward the financialization of health (Hunter & Murray, 2019), but demands us to understand its specificities within the Brazilian boundaries:

The attempt to open the black box of the financial area of an industry focused on health care is a considerable challenge and involves scrutinizing international financial spaces, examining the internal logic of adherence to financialization strategies, mapping tensions and conflicts between stakeholders, and understanding the origin and course of policies that provide the backdrop for markets, especially to avoid interpretations based on abstract predictions. (Bahia et al., 2016, p. S10)

6In this paper, we offer a novel approach to understanding the financialization of healthcare in Brazil, focusing on private provision. Our approach complements previous research as it provides an empirical assessment on how financialization unfolded in the private healthcare plans market in Brazil from 2007 to 2019. We focus on the examination of management strategies and behaviors registered in the balance sheets of leader operators in that market, based on empirical approaches to the financialization of the firm inspired by Davis (2016) and Rabinovich (2019). Moreover, we use a new dataset provided by ANS that compiles economic-financial data and the financial statements of healthcare plan providers.

7In addition to this introduction, the paper is divided as follows. Section 1 summarizes the theoretical and methodological approaches that will be used in the paper. Section 2 presents the criteria used to select the leader operators in the Brazilian market for healthcare plans and provides a general overview of main financial indicators. Section 3 presents the analysis of different indicators of financialization at the firm level and how they evolved over time, providing a critical assessment of leader operators financialization. Finally, our concluding remarks underscore the complexity of analyzing financialization in this market and outline a future research agenda.

1. Financialization: some methodological issues of empirical analyses

8Financialization can be understood as a systemic pattern of the reproduction of wealth in the entire economic system. Finance becomes the driving force of capital accumulation, establishing new ways to define, manage, and realize wealth (Braga, 1997; Braga et al., 2017). It affects the spending decisions of economic actors and impacts the relationship between markets and the State, shaping economic, social, and regulatory policies.

9After all, as it is systemic, it horizontally impacts all areas of social reproduction, and, in recent years, it has found a new niche for expansion in public services and social policies (Lavinas, 2017). As mentioned in the introduction, the provision of healthcare is no exception and represents a focal point of financialization (Hunter & Murray, 2019; Ferreira, 2022; Cordilha, 2023).

10Theoretical debates on the phenomenon of financialization are developed by different strands of economic thinking such as Marxist, Regulationist, and post-Keynesian economists–not to mention sociologists, anthropologists, and urbanists, among others (Zwan, 2014). In Brazil, a great deal of the healthcare literature has privileged the first two approaches, as they deal with economic and institutional changes associated with the process of financialization. As pointed out by Sestelo (2018a), healthcare has historically been thought of separately from the universe of national and global finance. Despite this, it has at least followed the processes of concentration, centralization, and internationalization of capital, especially of foreign controllers and investment funds (Andreazzi & Kornis, 2003; 2008; Hiratuka, Rocha & Sarti, 2016; Lavinas & Gentil, 2018). Likewise, other studies have assessed particular firms, developing qualitative analyses or reviews on the firms’ corporate evolution and financial results (Sestelo, Souza, & Bahia, 2013; Bahia et al., 2016; Sestelo, 2018a).

  • 4 There are several papers that discuss the changes firms have gone through due to financialization, (...)

11This paper proposes a methodological approach to analyze financialization in the Brazilian private healthcare plans market that differs from previous contributions. It takes as its starting point the internal changes at firms in the context of financialization,4 seeking to understand which characteristics of this process can be observed in such firms and how they manifest themselves empirically in indicators constructed from their balance sheets. Nevertheless, this task is not straightforward:

12The concept of the ‘financialization of the nonfinancial firm’ in the existing literature is unclear, reflecting the varied range of phenomena explored under the umbrella of financialization. While various changes in firm financial behavior have been isolated, the literature does not include a systematic discussion of the key stylized facts that summarize the ‘financialization of nonfinancial corporations’ or of how these changes in financial behavior are linked. It is, however, necessary to understand precisely how NFC financial behavior has changed before attempting to explain why these changes have occurred, or with what consequences. (Davis, 2016, p. 116).

13This picture becomes even more complex if the firms under analysis cannot be strictly characterized as non-financial firms: on the one hand, private healthcare plans aim to guarantee coverage of a good or service to their users, acting as a traditional non-financial firm; on the other, such firms intermediate the relationship between consumers and providers of medical services, acting as a third-party payer that manages financial resources, associated with the premium paid by individuals to protect themselves from the costs associated with the risk of getting sick. In parallel to this hybrid character, we must also understand the different types of organization of healthcare plans to identify how the ways of “defining, managing, and realizing wealth” centered on finance and financial assets affect the market.

14Those issues, however, does not invalidate our strategy: to take as our starting point the empirical analysis of the financialization of non-financial firms. The fact that healthcare plans firms manage financial resources does not preclude the possibility of an ever-increasing financial turn of accumulation in their management–i.e. an enhanced engagement in financial accumulation from which firms derive a growing part of their income and profits (Rabinovich, 2019). In addition, the ascendancy and dominance of shareholder value orientation in those firms should not be taken as a given feature of this sector, but need to be assessed empirically in order to understand the changes that such firms are going through in this new stage of capitalism.

15Davis (2016) centers her analysis on U.S. firms’ balance sheets, assuming that they reflect actual managerial decisions at the end of the day. She posits firms’ financialized behavior by associating it with the increase in the share of financial assets to their fixed capital in the investment portfolio, and through an increase in the leverage of large firms. Moreover, changes in the role of equity financing, expressed in the increase of stock buybacks, are also considered.

16Two additional contributions besides Davis (2016) are noteworthy, with a special focus on the Brazilian case. Fonseca, Silveira, and Hiratuka (2019) analyze the influence of institutional investors (investment funds, pension funds, insurance companies etc.) on the strategies of Brazilian non-financial firms listed on the Brazilian Stock Exchange (B3). The authors conclude that the presence of these investors does not modify dividend distribution, although they find a positive relationship between the weight of investments in financial assets and the magnitude of such dividends.

17Rabinovich and Artica (2020) analyze data from Latin American firms and verify that, only in the case of Brazilian non-financial firms listed in B3, it is possible to identify a positive relationship between financial investments and the financial income earned by such firms. They concluded that the shift of accumulation to the financial sphere seems to indicate adherence to the process of financialization.

At first glance, in the specific case of health insurance firms, we can identify the financialization process mainly from the following evidence:

(i) movements of entry and exit of global investment funds in equity holdings; (ii) public offerings of shares on stock exchanges; (iii) composition of multisector, multifunction and multinational holding companies; (iv) hypertrophy of the financial departments in non-financial companies. (Sestelo, 2018b, p. 2032)

18It is the combination of these theoretical and methodological perspectives that will guide the investigation of the process of financialization of the leading companies, i.e. leader firms, in the Brazilian health insurance market.

19As we have already indicated, the conventional literature is insufficient to deal with such a sui generis market, whose nature is both financial and non-financial. However, our concern now is to provide an empirical basis to demonstrate the qualitative changes underway, building a bridge between health economics, firms’ management strategies, and the movements recorded in their balance sheets.

  • 5 Although the focus is on publicly traded firms, it is important to emphasize that this logic is al (...)

20This work, therefore, has an exploratory character, where three groups of indicators will be evaluated, each associated with a hypothesis about the effect of financialization on such firms. The first hypothesis holds that financialization represents an increasing financial accumulation decoupled from the provision of services, from which firms will earn an increasing share of their profits. This would be reflected primarily by two indicators: (a) an increase in the share of financial assets over total assets and (b) an increase in the weight of financial profits in total profits (Rabinovich, 2019; Auvray & Rabinovich, 2019). The second hypothesis to be addressed concerns firms’ liabilities. Firms may enter into a process of financialization due to a growing dependence on third-party resources to finance their activities (Guttmann, 2018). As the level of outstanding debts increases, firms would be subject to the demands of creditors. This would be expressed in two possible ways: (a) a constant increase in leverage; and (b) an increase in financial expenses over profits. The third hypothesis deals more directly with publicly traded companies, i.e. firms whose shares are traded on stock exchanges. These firms would have registered a substantial change in the management process, no longer focused on the growth of the firms, but on the maximization of shareholder value (Zwan, 2014). This shareholder primacy will be investigated from the information disclosed by publicly traded firms.5 The underlying hypothesis is that financialized firms will be able to verify adherence to governance practices aligned with the maximization of shareholder value.

21In the next section, we will analyze these three groups of indicators, which can indicate whether and to what extent the leader firms in the health insurance plans market gravitate to the process of financialization in Brazil.

2. Characterizing the leader operators in the market of private healthcare plans in Brazil

22This section aims to respond to whether the leader operators–or leader firms–in the market of private healthcare plans are part of the financialization process. The selection of those operators is based on multidimensional criteria described below. Then, we provide a general description of their economic and financial situation, and, in sequence, we will evaluate how financialization penetrated the operation of these firms.

2.1. Selecting leader operators

23Leader firms are those capable of influencing the structure and dynamics of the private health insurance market as well as the regulatory policy of the State, seeking extraordinary profits and radicalizing the selection of actuarial risks. Given their reputation and capacity to distinguish products, they engage in a “pattern of competition” based on a struggle for corporate health plans in that market, seeking to increase premiums earned, verticalize their activity, and get economies of scale by increasing the number of young and healthy users. In addition, such firms are increasingly involved in the growth of mergers and acquisitions in the context of financial globalization (Ocké-Reis, Andreazzi & Silveira, 2006).

  • 6 Total assets were calculated by adding the assets of all the private health plan operators with an (...)
  • 7 We add the number of users of all private health plan operators with active registration with the (...)

24The selection of the leader firms (or operators) was carried out based on multidimensional criteria, namely: (i) the proportion of a firm’s assets to the sector’s total assets;6 (ii) the market share of each operator in terms of the number of users; (iii) whether the operator was publicly traded or not.7

25Firm Listed Propr-ietary network Type of organization Users (million)2 Market share2 Users Assets Amil1 - Yes Medical Group 3,1 6,6% 11,2% Hapvida Yes Yes Medical Group 2,4 5,2% 1,7% Qualicorp Yes - Benefits Manager - - 0,7% Central Unimed - Yes Medical Cooperative 1,7 3,6% 1,6% Unimed-BH - Yes Medical Cooperative 1,3 2,7% 2,3% Notre Dame Yes Yes Medical Group 2,5 5,2% 5,4% Bradesco Saúde - - Insurance Firm 3,4 7,2% 13,1% Sulamérica Yes - Insurance Firm 1,9 3,9% 7,6%

  • 8 Despite the particularities of the ownership structure of cooperatives, they are included in the s (...)

26Amil, Hapvida, and Notre Dame Intermédica are classified as Medical Groups among the selected firms. They have, in general, a vertical structure, offering care to users in their (own) proprietary network. The presence of this network of assistance ends up allowing the vertical management of costs, which can offer competitive advantages. Unimed - Belo Horizonte (BH) and Central Unimed are Medical Cooperatives that operate health insurance plans, have a vertical structure, with their proprietary network and/or accredited network, and enjoy the tax advantages associated with the cooperative system.8 Bradesco Saúde and Sul América are Insurance Firms and do not have their own network, as regulated by law–which sets that insurance firms must only offer health insurance plans, but not direct assistance. The selection also included Qualicorp, a Benefits Manager, which proposes the contracting of a group plan as a contracting party or provides services to legal entities contracting private plans, as defined by the regulatory agency. This type of organization operates in the middle of the market, offering options among healthcare plans to consumers, suitable to the profile of each user group.

  • 9 Except for operators organized as Odontological Group or Odontological Cooperative. Operators orga (...)

27At the end of 2019, leader firms had 16.2 million users, equivalent, in terms of market share, to 34.4% of total users. On the financial side, these operators totaled assets of around R$68.7 billion, accounting for 43% of the total assets of the firms registered with the Brazilian regulatory agency.9 Finally, if they compete on a national level, it is also possible to observe some geographical specialization (e.g. Unimed-BH).

2.2. The economic-financial performance of leader operators

28Since 2007, the Brazilian economy navigated through ups and downs in terms of economic performance. The 2008 international financial crisis had several impacts in the Brazilian economy, which pursued anticyclical macroeconomic policies that were effective in restoring a path of economic growth–at the time, the crisis was called a “ripple” by president Lula. After this rapid recovery, the slowdown of the economy eventually resulted in the 2015-2016 crisis, which was domestic in nature and highly idiosyncratic, as it was related to a massive judicial operation (Car-Wash) and culminated in the impeachment of the then president Dilma Rousseff.

  • 10 While it is not the purpose of this work to analyze the composition of operators’ assets in detail (...)

29The troubled scenario, however, did not impact the economic performance of the major healthcare plans operators. Despite a slight reduction in the size of the market, all the leader operators–but Qualicorp–had a significant increase in their assets.10 Their average total assets, at constant prices, have grown from a level of around R$2.5 billion in 2007 to R$8.6 billion in the last quarter of 2019 (Figure 1). Regarding the evolution of (net) profits, there is a clear trend of growth in the average profits, at constant prices, of such firms between 2013 and 2019 (Figure 2), reflecting a larger coverage of users and the inflation of healthcare plans (Ocké-Reis, Fiuza & Coimbra, 2019).

Figure 1. Average Assets from Leader Firms – 2007-2019(BRL billion, constant prices*)

Figure 1. Average Assets from Leader Firms – 2007-2019(BRL billion, constant prices*)

Figure 2. Average Annual Net Profits from Leader Firms – 2007-2019(BRL Million, constant prices*)

Figure 2. Average Annual Net Profits from Leader Firms – 2007-2019(BRL Million, constant prices*)
  • 12 Qualicorp was removed from the sample and treated as an outlier. Its numbers exhibit a singular be (...)

30The Return over Equity (RoE) informs about the profitability of the leader firms in the health insurance market. In Figure 3, we compare their performance with the average performance of the largest Brazilian non-financial firms (Pinto et al., 2019).12 One can see that leader firms operating in the market for health insurance plans obtained higher profitability than the large Brazilian non-financial firms in the whole period. In particular, in 2015, when non-financial firms had a negative profit rate due to the recession (-5%), the group of leader firms presented an average profitability of more than 15%. A comparison over the years indicates that the performance of such firms was two or three times the average rate of non-financial firms.

Figure 3. Return over Equity (RoE) from leader firms in the market for health insurance plans and the 500th largest non-financial firms in Brazil (%) – 2008-2019

Figure 3. Return over Equity (RoE) from leader firms in the market for health insurance plans and the 500th largest non-financial firms in Brazil (%) – 2008-2019

31The analysis of these results indicates that leader firms grew and had an extraordinary performance in the period. It is beyond the scope of this article to assess in detail the factors that explain such a scenario, but it is possible to associate that extraordinary results with a regulatory policy favorable to accumulation, for instance, allowing increases in the price of healthcare plans way above inflation (Ocké-Reis, Fiuza & Coimbra, 2019). Another explanation, which is gaining an increasing weight in the literature mentioned in Section 1, would be the change in the way those firms operate, adopting practices increasingly associated with a process of financialization. This hypothesis will be the focus of our investigation below.

3. Assessing the financialization of leader operators in the market of private healthcare plans in Brazil

32We dedicate this section to empirically evaluating whether and how the process of financialization may have impregnated the management of the leader firms in the market for health insurance plans in Brazil. This process will be analyzed from three distinct perspectives: the perspective of assets, liabilities, and the maximization of shareholder value. In particular, we build a set of indicators from data of financial statements provided by ANS, having as background the empirical literature on the financialization of the non-financial firm. We use both quarterly and annual data, depending on the indicator. The sample starts in the first quarter of 2007 and ends in the final quarter of 2019, encompassing all the periods provided in the ANS database.

3.1. Financialization of Assets

  • 13 Davis (2016), for example, analyzes the balance sheets of non-financial firms in the United States (...)

33Regarding the financialization in the asset side of firms’ balance sheets, the literature associates financialization with changes in the allocation of corporate assets: financial assets increase to the detriment of fixed capital assets, indicating a change in the mode of accumulation of those firms. The focus of the business model is shifted: in the case of operators of health insurance plans, this focus would shift from the intermediation of the provision of services–and their financing–to a rentier dynamic without direct links to their core businesses.13

34Therefore, we use as the first indicator of the financialization of assets in a firm the ratio of financial assets over total assets (FI1):


35However, considering the Brazilian National Health Agency regulatory policy, since 2007 it was required that operators involved in the business of health insurance plans maintain liquid and safe assets in their portfolios for prudential purposes. Therefore, one can refine FI1 to reflect more accurately genuine a firm’s investment decision in financial assets.

36In other words, part of the investment in financial assets is motivated by regulatory standards, and, in this case, such a trend is not a genuine decision of the firms detached from their obligations to health plan users. So, an appropriate measure should consider only those financial assets that are not linked to consideration, the so-called “free” financial assets (FI1A):


37Figure 4 shows the evolution of the average FI1A of the leader firms and the market as a whole. In the comparison, the relative participation of the leaders’ free financial assets is higher only between 2007 and 2011, reaching almost 30 %. From then on, there is a strong contraction in the indicator, which is accentuated until the end of the period, when a decline from 20 % to 15 % occurs.

Figure 4. Free Financial Assets over Total Assets, leader operators’ and non-leaders’ average – 2007-2020 (%)

Figure 4. Free Financial Assets over Total Assets, leader operators’ and non-leaders’ average – 2007-2020 (%)

38Thus, the evaluation of the average FI1A does not support the hypothesis that, on average, financialization has expanded among the leader firms through the expansion of the weight of financial assets. When analyzing individual results, however, we can see some heterogeneity in the results. Bradesco Saúde and SulAmérica, both insurance firms, present an increase in the proportion of free financial assets from 2007 to 2020 (Figure 5). In the first case, this expansion was not uniform during that period, with a period of decrease followed by a subsequent increase. This trend was presented by Hapvida too.

39Such a change in the stock of assets is reflected in the flows, in particular in the weight that financial revenues have in total revenues. We thus construct a second indicator of financialization from the asset side (FI2), which expresses the ratio between the following variables:


40This index expresses the rent-seeking character of financialization, a result of the income generated by financial assets, which can influence or even determine the dynamic of the firms’ revenues. Figure 6 shows that there is a proximity between FI1A and FI2: one can identify a slight trend of expansion (on the average of leader operators, it increased from 2.5 % in 2007 to 3.2 % in 2019), but the weight of financial revenues in total revenues is quite small. This means that their process of accumulation was not based on rent-seeking, a phenomenon noted in several contributions in the financialization literature (Krippner, 2005).

Figure 5. Percentage share of free financial assets in the total assets of the leader operators – 2007-2020 (%)

Figure 5. Percentage share of free financial assets in the total assets of the leader operators – 2007-2020 (%)

Figure 6. Percentage share of financial revenues in the total revenues of the leader operators – 2007-2020 (%)

Figure 6. Percentage share of financial revenues in the total revenues of the leader operators – 2007-2020 (%)

41It is necessary, therefore, to have more elements to properly characterize the process of financialization of such companies. In this sense, we should observe not only how financialization is expressed on the assets side of the balance sheets of firms in the health insurance market, but also on the liabilities side, that is, the financial obligations contracted by these companies.

3.2. Financialization of Liabilities

42Davis (2016) proposes that two stylized facts can be associated with the financialization of non-financial firms in the structure of liabilities. First, she points out that the increase in gross debt would be an expression of financialization. Second, an increase in the firms’ leverage ratio is also considered to reflect the deepening of financialization. In the second case, Davis uses the average and the mean of the debt over equity as financialization indexes–such ratios are classic leverage indexes. In the literature, it is admitted that financialization would be accompanied by an increase in leverage, making firms more susceptible to the demands of lenders and more financially fragile.

43In addition to this, we add an indicator that shows how much of the firms’ total expenditure is exclusively allocated to the payment of financial expenses. Thus, we build two indicators: one to measure the degree of leverage (FI3) and another to measure the ratio between financial expenses and total expenses (FI4), which are calculated as follows:


44Figures 7 and 8 show that it is not possible to identify a generalized increase in leverage, nor in the commitment of firms’ resources to financial expenses. On the contrary, a deleveraging process of the leading health insurance firms persists, and a residual percentage of the weight of financial expenses is evident.

Figure 7. Leverage (IF3) of leader operators – 2007- 2020

Figure 7. Leverage (IF3) of leader operators – 2007- 2020

Figure 8. Percentage share of financial expenses in the total expenses of the leader operators* (IF4) – 2007-2019 (%)

Figure 8. Percentage share of financial expenses in the total expenses of the leader operators* (IF4) – 2007-2019 (%)

45The SulAmérica case is the only one that seems to break the general trend: there was a significant increase in leverage in mid-2013; then it decreased but stays at a higher level than at the beginning of the period. Hapvida and Bradesco went through processes of increasing leverage in the first half of the 2010s, but this trend has been reversed in recent years.

46The analysis of the two indicators of financialization of liabilities suggests that the structure of the obligations of the leader firms does not point to a “leakage” of funds towards the financial system and other creditors. In the literature, the combination of such a “leakage” and an increase in financial fragility is associated with the subsumption of these firms to financial institutions. However, our data shows that this was not the way by which the process of financialization took place in the leader firms operating in the private health insurance market in Brazil.

47At this point, it is worth relating this result to another indicator analyzed earlier: firms’ profitability. It is important to recognize that the dynamics of leader firms’ profits reinforced their capital position, with a large potential for accumulating and retaining earnings. Such incomes were not leaked via financial obligations, favoring their owners. Moreover, the initial public offerings conducted by a part of these leader firms also operated in the sense of reinforcing their equity base, therefore favoring an approach that relied more on the extension of shareholder basis than on debt.

3.3. Maximization of Shareholder Value

48The literature on the financialization of non-financial firms also analyses the changes in firm behavior from the viewpoint of the primacy of shareholders, or the maximization of shareholder value (Lazonick & O’Sullivan, 2000). The primacy of shareholder value is materialized by the alignment of incentives and interests between managers and shareholders in corporate governance practices:

Shareholder value has been associated with a particular set of business practices, including the introduction of financial performance measures such as return on equity, the adoption of international accounting standards, and a short-term business outlook as manifested by the publication of quarterly reports. (Zwan, 2014, p. 108)

  • 14 It is worth noting, although they can be observed in private firms, such characteristics prevail i (...)

49The process, however, goes beyond these most basic elements and is expressed in several dimensions, synthesized by the adoption of so-called best practices of corporate governance (Froud et al., 2006). It is also expressed through practices including the concentration and centralization of capital (mergers and acquisitions as well as outsourcing of non-profit activities) and the distribution of dividends and share buybacks (Davis, 2016; Zwan, 2014).14

  • 15 Amil was listed until 2013, but closed its capital after being acquired by UnitedHealth.

50Among the selected leader firms, four currently have shares listed on the Brazilian Stock Exchange (B3): Hapvida, NotreDame, Qualicorp, and SulAmérica.15 SulAmérica has been publicly traded since 2007 and Qualicorp since 2011. NotreDame and Hapvida entered this process more recently, in 2018.

  • 16 The complete list of governance practices in B3’s New Market can be found in the following link: h (...)
  • 17 In particular, the main difference is the possibility of maintaining preferred shares, which do no (...)

51Hapvida, NotreDame, and Qualicorp have joined the so-called New Market (Novo Mercado), a differentiated stock listing segment of B3. It brings together firms that voluntarily follow corporate governance practices that go beyond those required by financial regulation in Brazil–including transparency, minimum free-floating ratios, independent directors, dividends distribution etc.16 All such practices were directly aligned with shareholder-value orientation in the terms of Lazonick and O’Sullivan (2000). SulAmérica is also listed in a differentiated corporate governance segment, Level 2, similar to the New Market, but with some particularities.17

  • 18 A detailed analysis of this phenomenon is beyond the scope of this paper, but it illustrates the a (...)

52Analyzing the material facts released by those firms, it is possible to observe an intense activity of the operators Hapvida and NotreDame in acquiring stakes in other health groups recently (2018-2020), providing an increase in the concentration of capital in the market (Table 2).18 This behavior does not seem to be related to any institutional change in market rules, but the result of a strategy of acquiring other smaller firms, limiting competition in the market, and expanding the number of clients for the provision of healthcare plans.

53Finally, it was found that all publicly traded firms have recently presented stock buyback programs, despite the context of the health crisis associated with the Covid-19 pandemic. As Davis (2016, p. 131) highlights:

Stock repurchases are one clear manifestation of growing managerial emphasis on the maximization of ‘shareholder value’. By repurchasing the firm’s stock, managers improve–for given profits–stock-market-based measures of firm performance including the (short-term) share price, return on equity, and earnings per share.

  • 19 Again, we will not conduct a detailed analysis of this issue, but only use these facts as an illus (...)

54Typically, repurchase transactions demand resources for their financing, which could be employed for other purposes, especially productive investments (Davis, 2016).19

Date Operator Material Fact Firm/Group Name or Description
07/05/2019 Hapvida Acquisition São Francisco
09/06/2019 Hapvida Acquisition Firms from América Group
03/12/2019 Hapvida Acquisition Medical
13/12/2019 Hapvida Acquisition Plamed’s portfolio of beneficiaries
28/04/2020 Hapvida Shares Buyback Up to 21,704,063 stocks (10% total) until 28/10/21
15/07/2020 Hapvida Acquisition São José Group
08/09/2020 Hapvida Acquisition Promed Group
19/06/2018 NotreDame Acquisition Samed
18/07/2018 NotreDame Acquisition Mediplan Sorocaba Group
05/09/2018 NotreDame Acquisition Greenline
08/04/2019 NotreDame Acquisition Amiu
27/05/2019 NotreDame Acquisition Belo Dente
25/07/2019 NotreDame Acquisition Ghelfond Group
16/09/2019 NotreDame Acquisition SMEDSJ Group
01/10/2019 NotreDame Acquisition São Lucas Group
01/11/2019 NotreDame Acquisition Clinipam
17/12/2019 NotreDame Acquisition Ecole
09/01/2020 NotreDame Shares Buyback Up to 3,400,000 stocks (0,6% total) until 08/07/20
20/05/2020 NotreDame Acquisition Hospital do Coração [Heart Hospital]
25/06/2020 NotreDame Acquisition Santa Mônica Group
04/08/2020 NotreDame Acquisition Climepe
12/08/2020 NotreDame Acquisition Bio Saúde
26/08/2020 NotreDame Acquisition Medisanitas
14/01/2020 Qualicorp Divestiment QSaúde
03/09/2020 Qualicorp Shares Buyback Up to 10,000,000 stocks (3,5% total) until 17/02/22
08/10/2018 SulAmérica Acquisition Prodent
13/05/2019 SulAmérica Investment Órama Distribuidora de Títulos e Valores Mobiliários [Órama Securities Distributors]
13/05/2020 SulAmérica Shares Buyback Up to 13,977,551 units (3.55% total) until 14/11/21
05/06/2020 SulAmérica Acquisition Paraná Clinics

Source: Firms’ Investor Relations websites.

3.4. Synthesis

55Our analysis adopted a different way to approach the financialization of health in Brazil, focusing on an empirical investigation of the financialization of firms operating in the market for health insurance plans from 2007 to 2019.

56In terms of financialization of assets, on the one hand, when we analyze the free financial assets, disconnected from prudential rules, their weight in Bradesco, SulAmérica, and Hapvida stands out. On the other hand, the low relevance of financial revenues in the leader firms’ total earnings indicates, at first sight, that their accumulation process was not redirected towards rent-seeking. It does not seem that there are relevant differences in the results of different organizational structures: cooperatives, insurance firms, medical groups or benefit operators share the same general feature of a small participation of financial over total earnings.

57In terms of financialization of liabilities, it seems that it is not possible to sustain the increased dependence on indebtedness and the leader firms’ subjection to creditors or high financial costs: these firms have shown themselves to be less dependent on financial obligations, with a reduction in the degree of leverage and a contained exposure to financial expenses. Again, this can be considered a general feature of leader operators despite their different organizational structures.

58Turning to shareholder value, we believe that the financialization of leader firms in the provision of health insurance plans has been underlined through this process, but we recognize that the paper faced some limitations to properly assess this aspect due to the nature of the balance-sheet database. The change in their capital structure, with many of them becoming listed, their active involvement in mergers and acquisitions of smaller firms, and the realignment of managerial practices with corporate governance standards established in the capital market were the material channels through which financialization took place. Likewise, the adherence to the share buyback logic signals the incorporation of shareholder primacy into the day-to-day life of these firms.

59The evidence therefore points out that leader firms in the market for health insurance plans in Brazil have become relatively more financialized between 2007 and 2019, but in an “incomplete” way: data indicates that this financialization process is still in progress, though it is far from the way firms in countries with a higher degree of capitalist development are financialized. One can expect that as ownership structures evolve and the shareholder value logic perpetuates, we will see a movement towards financial rent-seeking and greater subsumption of those firms to the interests of lenders and financial markets.


60This paper investigated how the process of financialization of health developed in Brazil, focusing on the adherence to financialization strategies by leader firms in the market for health insurance plans in the period from 2007 to 2019. Our main purpose was to offer a contribution that gives materiality to the general interpretations of financialization in the Brazilian case, explaining how that process took place in this market and the general area of health from an empirical perspective.

61Our approach took as a main reference the methodology employed in part of the literature on the financialization of non-financial firms, especially Davis (2016) and Rabinovich (2019). Based on real-world data and some stylized facts consolidated in the literature, we identified and examined the internal logic of the adherence to financialization strategies by the leader firms in the market for health insurance plans.

62With the compilation of data on financial and income statements made available by the ANS and the building of a set of financialization indexes used in the literature, we believe our paper is the first that uses this approach to analyze the financialization of health from such a perspective. Our methodology was guided by the need to provide material insights about how financialization took place in leader firms in this sector, rather than focusing on case studies or aggregated analyses, a gap already filled by other contributions in the Brazilian literature (Sestelo, 2018b).

63Our main conclusion is that the process of financialization of the main healthcare plans operators presents characteristics that differentiate it from the one usually found in literature (Davis, 2016; Rabinovich, 2019; Rabinovich & Artica, 2020). Part of this can be due to their hybrid nature, acting as non-financial and financial firms at the same time, but the main possibility is that the leader operators have served more as a platform for third-party financial accumulation–adhering to the logic of shareholder primacy–than properly breaking with the business model of the healthcare plans market, which focused on the intermediation of financing and the provision of private medical-hospital services.

64The transformation of “population ill-health into zones for investment”, as pointed out by Hunter & Murray (2019), is undeniable, as leader operators in Brazil engage in a series of activities to generate profits, from asset management to day-to-day medical-hospital operations and the administration of claims ratios. However, the dominance of finance still has to face a long road, when compared with developing economies. Leader operators are increasingly becoming recipients of financial capital, though the consequences of this process are not clear yet. Recently, the introjection of a short-term logic in their operations can be related to an increasing limitation on healthcare access by the general population, which resorts to private health market for medical appointments and exams due to the large waiting lists at SUS, and a more precarious coverage and provision of services (Bahia & Scheffer, 2018). As financialization advances, the perspective is that financial aspects will govern the day-to-day of healthcare plans operators and the Brazilian population that benefits from such plans will be neglected for financial profits.

  • 20 See Lavinas, Araújo & Gentil (2020) for an example of econometric methodology to assess the financ (...)

65In this paper we did not intend to provide a final verdict, but rather to complement and reinforce the relevant research in the area. As a research agenda, we can point out at least two paths to be followed: (i) the analysis of the process of concentration and centralization of capital in the health insurance market; and (ii) the analysis of the pattern of investments by healthcare plan operators, aiming to identify if there will be a repositioning of the weight of free financial assets and financial revenues shortly. In addition, we must critically consider if the methodology we have taken as a reference is sufficient to answer the raised questions. It is possible to imagine alternative ways to empirically evaluate financialization, especially in peripheral countries, but, due to space limits, the development of this critique is also a point that is a part of this future agenda. 20

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Document annexe

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1 According to Palludeto and Rossi (2022, p. 551): “Fictitious capital can be understood as capital value in the form of a tradable claim on a future flow of income”. This category is defined by three main attributes: (i) the existence of a future flow of income that will be capitalized at the conventionally accepted benchmark rate to form capital in the present; (ii) the existence of secondary markets in which the process of capitalization takes place and capital will be “re-evaluated by all capitalists constantly and in real time” (Ibid, p. 552); and (iii) the “real nonexistence” that assures the purely financial nature of that type of social relation. An example might help the reader that is not familiarized with this discussion: “The issuance of stocks, for instance, immediately originates fictitious capital by creating an ownership title that circulates as capital alongside the real capital it represents […] Such capital value is nothing more than the present value of the flow of income to which the owner of the security is entitled to receive. The price of the stock is not determined as if it were the company’s capital but rather as a capitalized quota of its future income. Accordingly, stocks should not be interpreted as part of industrial capital, nor should fictitious capital be interpreted as straightforward pricing of real capital” (Palludeto & Rossi, 2022, p. 553, our highlights).

2 According to the World Health Organization (2023): “Universal health coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. It covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care.”

3 For a description of the Brazilian health system, see Ferreira (2022) and Cordilha (2023, 176-196).

4 There are several papers that discuss the changes firms have gone through due to financialization, both from discussions of the globalization of capital (Chesnais, 1996) and in the recently published Routledge International Handbook of Financialization (Mader, Mertens & Zwan, 2020).

5 Although the focus is on publicly traded firms, it is important to emphasize that this logic is also reproduced in private firms, as we can observe in the actions of private equity funds and other financial actors that have come to exercise greater control over the management of health insurance carriers (Lavinas & Gentil, 2018; Bahia, 2013).

6 Total assets were calculated by adding the assets of all the private health plan operators with an active registration with the ANS, except for operators organized as Odontological Group or Odontological Cooperative. The exclusion is justified because of the offer of differentiated products and services that do not compete freely with health plans focused on medical assistance. Some larger operators, however, operate in both the medical care and dental care areas. After the exclusions, the sample totaled 832 firms, whose total assets were R$158 billion as of December 2019.

7 We add the number of users of all private health plan operators with active registration with the ANS, except those operators organized as Odontological Group or Odontological Cooperative because analyzing the market of dental care plans is beyond the scope of this paper.

8 Despite the particularities of the ownership structure of cooperatives, they are included in the sample because they operate as relevant healthcare plan providers in this market and compete directly with other players. One can posit that such ownership structure is unfavourable to a process of financialisation, but we do not take this result as granted a priori.

9 Except for operators organized as Odontological Group or Odontological Cooperative. Operators organized under the form of Self-Management firms were not included in the sample of leader firms because they compete in a specific niche of the market, which is not widely open to the general public. They are, however, part of the total market assets used as reference in this paper.

10 While it is not the purpose of this work to analyze the composition of operators’ assets in detail, data shows on average a symmetrical division between short-term and long-term assets, which ensures a high level of liquidity in the balance sheets of these companies. The largest asset class is short-term financial investments (on average, 35%), which comply with the regulations of the National Health Agency to ensure that these firms can meet healthcare expenses from their clients in a timely manner. Furthermore, during the analyzed period, these firms operated with a low level of leverage and, therefore, a high equity/assets ratio (on average, 45%), indicating a comfortable solvency situation for most of the firms.

12 Qualicorp was removed from the sample and treated as an outlier. Its numbers exhibit a singular behavior, which reflected an idiosyncratic trajectory of the firm’s net worth prior to its initial public offering. For instance, Qualicorp’s RoE was 546,1% in 2010 and 70% in 2011 when it became listed.

13 Davis (2016), for example, analyzes the balance sheets of non-financial firms in the United States between 1950 and 2014 and finds that firms began accumulating financial assets at an increasing rate relative to fixed capital assets. The author uses as indicators the items ‘financial assets’ and ‘fixed capital assets’ weighted by firm size (sales volume), calculating the median for her sample of firms.

14 It is worth noting, although they can be observed in private firms, such characteristics prevail in publicly traded or publicly listed firms.

15 Amil was listed until 2013, but closed its capital after being acquired by UnitedHealth.

16 The complete list of governance practices in B3’s New Market can be found in the following link: (acessed on 11th June 2024).

17 In particular, the main difference is the possibility of maintaining preferred shares, which do not confer voting rights to the shareholder, for a given part of the capital.

18 A detailed analysis of this phenomenon is beyond the scope of this paper, but it illustrates the adherence of these firms to this dimension–maximization of the shareholder value–of the financialization process.

19 Again, we will not conduct a detailed analysis of this issue, but only use these facts as an illustration of the alignment of the practices of publicly traded firms with the logic of the primacy of shareholder value.

20 See Lavinas, Araújo & Gentil (2020) for an example of econometric methodology to assess the financialization of non-financial firms.

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Table des illustrations

Titre Figure 1. Average Assets from Leader Firms – 2007-2019(BRL billion, constant prices*)
Fichier image/jpeg, 61k
Titre Figure 2. Average Annual Net Profits from Leader Firms – 2007-2019(BRL Million, constant prices*)
Fichier image/jpeg, 26k
Titre Figure 3. Return over Equity (RoE) from leader firms in the market for health insurance plans and the 500th largest non-financial firms in Brazil (%) – 2008-2019
Fichier image/jpeg, 58k
Titre Figure 4. Free Financial Assets over Total Assets, leader operators’ and non-leaders’ average – 2007-2020 (%)
Fichier image/jpeg, 58k
Titre Figure 5. Percentage share of free financial assets in the total assets of the leader operators – 2007-2020 (%)
Fichier image/png, 289k
Titre Figure 6. Percentage share of financial revenues in the total revenues of the leader operators – 2007-2020 (%)
Fichier image/png, 343k
Titre Figure 7. Leverage (IF3) of leader operators – 2007- 2020
Fichier image/png, 285k
Titre Figure 8. Percentage share of financial expenses in the total expenses of the leader operators* (IF4) – 2007-2019 (%)
Fichier image/png, 350k
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Norberto Montani Martins et Carlos Ocké-Reis, « The financialization of healthcare »Revue de la régulation [En ligne], 36 | 1er semestre|Spring 2024, mis en ligne le 25 juin 2024, consulté le 20 juillet 2024. URL : ; DOI :

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Norberto Montani Martins

Professor, Institute of Economics, Universidade Federal do Rio de Janeiro (UFRJ), Brazil,

Carlos Ocké-Reis

Senior Research and Planning Advisor, Instituto de Pesquisa Econômica Aplicada (Ipea), Brazil.

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Le texte seul est utilisable sous licence CC BY-NC-ND 4.0. Les autres éléments (illustrations, fichiers annexes importés) sont « Tous droits réservés », sauf mention contraire.

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