Determinants of alignment level with public health risk management under COSO - ERM: Commentaries

1. Introduction

These comments are part of the Revista Contabilidade & Finanças Special Edition, which aims to bridge the gap between academia and practice. Specifically, the following comments analyze the article titled “Determinants of the Level of Alignment with Risk Management in Public Health Under COSO - ERM”, authored by Carla Nobre Rêgo and Jerônimo José Libonati (2025). The document is structured into two sections: the first presents the comments of Prof. Dr. Ilse Maria Beuren, a faculty member in the Graduate Program in Accounting at the Federal University of Santa Catarina; the second section includes the comments of Prof. Dr. Josedilton Alves Diniz, an external control auditor at the Court of Accounts of the State of Paraíba.

2. Comments by Ilse Maria Beuren

2.1 Study Context

The paper by Rêgo and Libonati (2025), titled “Determinants of the Level of Alignment with Risk Management in Public Health Under COSO - ERM”, published as part of the Revista Contabilidade & Finanças Special Edition, stemming from the 2024 USP International Conference in Accounting, examines the determinants of risk management practice alignment in Brazilian municipal health management. The research field encompassed 456 health regions distributed across Brazil's 27 federative units, along with an additional 17 municipalities in cases where these regions did not represent the largest population. To conduct the survey, municipal ombudsperson offices were contacted to obtain the details of the Municipal Controller (or equivalent) and the Secretary of Health (or equivalent), resulting in 109 valid responses from 55 municipalities.

Risk management practices were analyzed using the Committee of Sponsoring Organizations of the Treadway Commission - Enterprise Risk Management Integrating with Strategy and Performance (COSO-ERM) framework. Specifically, the study employed the updated 2017 COSO-ERM (or COSO II) framework, Integrating with Strategy and Performance, an evolution of the Enterprise Risk Management - Integrated Framework (COSO, 2004) and the Internal Control (COSO-IC or COSO I) - Integrated Framework (COSO, 1992). The framework was selected due to its emphasis on the importance of risk management in organizational activities and strategic implementation, as well as its widespread adoption, including by Brazil’s National Agency for Supplementary Health (ANS-Agência Nacional de Saúde Suplementar).

The determinants of alignment in these practices were examined in relation to the managers' profiles and the municipalities' socioeconomic characteristics. The managers’ profiles were captured through a survey conducted between December 19, 2022, and May 19, 2023, collecting data on respondents’ roles, tenure in office, time in the position, academic background, and educational level. The socioeconomic characteristics of the municipalities were established based on secondary data and analyzed for health, education, and information technology governance effectiveness, indebtedness (determined by the ratio of unpaid commitments registered in public health, accumulated from 2013 to 2020, to 2020 municipal revenue) and financial dependence (determined by the ratio of current transfer revenue minus indirectly collected taxes to operating revenue, i.e., to current revenue.

Descriptive statistical analyses were conducted following the measurement of the dependent variable-the level of alignment in risk management practices-via the survey and the collection of secondary data based on parameters to operationalize the determinants. Two samples were formed to analyze the alignment level of risk management practices in Brazilian municipalities, aiming for proximity to half the dataset. Perception data on risk management revealed that, of the 109 valid responses, 59 (54.13%) were from Municipal Controllers and 50 (45.87%) from Health Secretaries. Regarding the socioeconomic characteristics of the municipalities, complete data for all variables were available for 29 municipalities associated with Municipal Controllers and 21 municipalities associated with Health Secretaries.

Regression analysis with all variables within a single model proved unsuitable for hypothesis testing, leading to the removal of the constant from the equation. Subsequently, the variables were tested in various configurations, with risk management as the dependent variable, and the tests were segmented between Municipal Controllers and Health Secretaries. The first three hypotheses yielded contrasting results between these groups, while the latter three hypotheses showed consistent outcomes. The findings confirmed that determinants of the alignment of risk management practices in municipal health administration include the manager’s profile for both groups, health effectiveness for Municipal Controllers, and education and information technology governance effectiveness for Health Secretaries. Conversely, indebtedness and financial dependence were not significant determinants for either group.

2.2 Practical Relevance

The study demonstrates practical relevance by offering insights into various aspects of risk management. First, using the COSO ERM - Integrating with Strategy and Performance framework (COSO-ERM, 2017) as a reference facilitates alignment among stakeholders with the evolution of COSO's proposed best practices and responsiveness to the demands of a dynamic environment. Second, the focus on the components and principles updated in the framework may inspire regulators and managers in their practices, guided by governance and culture, strategy and goal-setting, performance, review and revision, and information, communication, and reporting (COSO-ERM, 2017). Third, considering that COSO was established in the United States in 1985 as a private-sector initiative (COSO, 1992), adapting this framework to municipal health management constitutes a significant contribution, given the idiosyncrasies of the public sector.

The indicators and metrics proposed in the study, representing determinants of alignment in risk management practices for municipal public health, can draw attention to critical factors and inspire further research. On the one hand, the supported hypotheses highlight the importance of manager profiles and municipal characteristics that influence alignment in risk management practices within municipal health management. On the other hand, new research could explore why the alignment of risk management practices with the COSO-ERM model does not show an inverse association with the level of indebtedness or the degree of financial dependence of the municipalities in the sample. This could provide explanations for the hypotheses not supported in the study.

The proxy employed in this study to determine the alignment level of risk management practices in municipal public health management, along with the established regression models, provides significant theoretical and empirical contributions. The literature remains silent on potential parameters that could assist in identifying such alignment and in proposing models to assess the suggested relationships. Consequently, this paper can stimulate discussions about variables that could potentially be integrated into the model and their operationalization, including empirical testing frameworks. The lack of statistical significance in hypotheses such as municipal indebtedness levels and financial dependence highlights the need for further studies to explore answers within the theoretical and empirical domains.

Lastly, divergent results were observed in the analyses segmented between Municipal Controllers and Health Secretaries. The differences in their perceptions may stem from their distinct roles in risk management within municipal health administration. Consistent with their positions, the alignment level of risk management practices was positively associated with healthcare expenditure effectiveness exclusively for Health Secretaries. Conversely, it was associated with higher education levels among the population and greater use of high-quality information technology systems only for Municipal Controllers. Therefore, these findings have important implications for organizations and should be on the radar of regulators, managers, researchers, educators, and others interested in municipal public health risk management.

2.3 Relevant Practical Issues Not Explored in the Paper

The paper offers significant theoretical and empirical contributions regarding the profile of managers and the characteristics of municipalities that may influence the alignment of risk management practices in municipal public health management, as well as the alignment level based on the study’s established proxy. While the study’s relevance is acknowledged, the hypothesis testing results reveal inconsistencies that encourage further empirical investigation. Future research could delve into this context, providing implications for the literature and managerial practice aligned with New Public Management (NPM) principles (Bryson et al., 2014). A multi-group analysis could yield additional evidence on the differing perceptions between Municipal Controllers and Health Secretaries regarding the level of risk management in municipal health administration.

The positive association between the alignment level of risk management practices and healthcare expenditure effectiveness (health effectiveness) for Health Secretaries, but not for Municipal Controllers, appears inconsistent. Both roles are expected to prioritize efficiency in public health expenditures (Saldiva & Veras, 2018). Similarly, the confirmed association with higher education levels among the population (education effectiveness) and greater use of high-quality information technology systems (governance in technology effectiveness) exclusively for Municipal Controllers also seems inconsistent, as these variables should ostensibly concern both Health Secretaries and Municipal Controllers. In fact, the Municipal Management Effectiveness Index (IEGM), encompassing health, education, and governance, is of shared interest, underscoring research gaps that warrant further exploration.

Analyzing the population density of municipalities and the impact of higher (lower) levels of education among the municipal population using statistical techniques, such as differences in means, could substantiate differentiated risk management practices in municipal public health administration. This approach could also inform the formulation of public policies that support discretionary investments in prevention over correction (Fittipaldi et al., 2021). Furthermore, examining the quality of information technology systems, such as the degree of system integration (Chapman & Kihn, 2009), could help establish a structure that enhances service delivery quality for citizens (Peeters et al., 2023). Examples include integrated medication inventory control, interconnected appointment scheduling for exams, and reduced waiting times.

The study hypothesized that the alignment level of risk management practices with the COSO-ERM model would be inversely associated with municipal health-related indebtedness and financial dependency. However, no statistical support was found for these relationships. These results may have been influenced by two indicators pointing toward liabilities yet representing distinct dimensions. This issue, particularly when considering municipalities of varying sizes, encourages further analysis, such as examining federal resource transfers to municipalities, known as Voluntary Transfers (Moutinho, 2016). Although these transfers are intended to serve mutual interests under the Fiscal Responsibility Law, the granting authority may demand more from recipients than the transfers represent, potentially affecting municipal debt levels. Additionally, this raises the question of how financial dependency might hinder potential investments in risk management practices for municipal health administration.

Although the alignment level of risk management practices with the COSO-ERM model in municipal health management demonstrated an association with the profile of the managers, other factors may contribute to explaining the phenomenon, such as political-partisan dynamics and behavioral characteristics (e.g., leadership, teamwork) of the survey respondents. Beyond the proposed suggestions for including new independent variables in the model, further reflection on the measurement instrument used to assess risk management practices in municipal public health is encouraged, along with efforts to reinforce its internal and external validity. Finally, researchers and practitioners are urged to engage in discussions and evaluations of the established proxy used to assess the alignment level of risk management practices in municipal public health management, using the COSO-ERM framework as a reference.

2.4 Conclusion

The study by Rêgo and Libonati (2025) offers significant practical contributions by encouraging reflections on various dimensions of risk management, notably (i) the selection of a framework to evaluate best practices in risk management, specifically the COSO ERM - Integrating with Strategy and Performance (COSO-ERM, 2017), and its adaptation to municipal health management considering the public sector’s unique characteristics; (ii) the development of indicators and metrics that represent the determinants of alignment in municipal public health risk management practices; and (iii) the establishment of a proxy to measure the alignment of these practices with the COSO-ERM framework and the use of regression models. By exploring this area, the study’s findings align with managerial practices advocated by the New Public Management (NPM) approach.

However, a critical analysis reveals that explanatory factors for the study’s findings remain as research gaps. One critical practical issue deserving further investigation beyond the managers’ profiles is directing attention to the multilevel actors involved in municipal health management and differentiating between appointed and career civil servants. Similarly, the scope of municipal characteristics considered to identify determinants of the alignment of risk management practices is relatively narrow. Another issue requiring greater attention is the inconsistency observed in the alignment of risk management practices with the COSO-ERM model, which did not exhibit an inverse association with municipal indebtedness or financial dependency levels.

Future research could explore variables potentially enhancing the model, focusing on their operationalization and testing. Behavioral aspects (e.g., leadership, teamwork), the roles of multilevel actors, the employment status of public servants (appointed or career), the quality of technological systems (e.g., system integration and use of artificial intelligence), and the political-party identity of local public units could provide valuable explanatory insights into the alignment of risk management practices with the COSO-ERM model. Moreover, the research could further investigate the lack of statistical significance in the inverse association between the alignment of risk management practices with the COSO-ERM model and municipal indebtedness and financial dependency. Indebtedness, for instance, may be influenced by imbalances between resource transfers and the demands imposed by granting authorities. Similarly, financial dependency may hinder investments in risk management practices within municipal health management. Addressing these aspects could advance both theoretical understanding and practical applications in public sector risk management.

3. Comments by Josedilton Alves Diniz

3.1 Study context

The article by Rêgo and Libonati (2025) examines a topic of great relevance to public administration in Brazil: the determinants of alignment with risk management practices in municipal public health, based on the Committee of Sponsoring Organizations of Enterprise Risk Management (COSO-ERM) framework (COSO, 2017). Due to the administrative decentralization promoted by the Unified Health System (SUS), municipal governments play a crucial role in the implementation of health policies. However, as highlighted in the study, this decentralization also exposes managerial weaknesses that directly impact both the efficiency of resource allocation and the quality of the services provided (Matos, 2012).

The discussion presented in the article underscores the importance of risk management as a tool to mitigate issues such as resource mismanagement, corruption, and operational inefficiency. These arguments point to the existence of inefficient fiscal policies in the public health system and indicate that higher financial outlays do not necessarily translate into better health conditions; thus, the article positions itself within a critical debate (de Mendes et al., 2022). These elements reinforce the need to improve the management of public resources by incorporating managerial skills, technical training, ethics, and effective control instruments-such as risk management (TCU, 2020).

The study acknowledges and addresses the gap in the literature on municipal public health management, seeking to fill it by exploring how internal factors, such as the profile of managers (academic background, education, experience), and external factors, such as the socioeconomic characteristics of municipalities, influence alignment with COSO-ERM (Silva, et al., 2021). This thematic choice is relevant and provides insights into governance within the public sector.

However, the introduction could have delved deeper into the current state of risk management in Brazilian public health by incorporating empirical data or references from previous studies that illustrate the challenges faced by municipalities in implementing structured management practices. Such context would more robustly justify the choice of the research problem and reinforce the relevance of the study, thereby strengthening the connection between the investigated determinants and the expected outcomes.

Although this gap in the introduction does not compromise the merit of the work, a more detailed account of the practical challenges faced by municipalities would help better contextualize the impact of risk management practices and reinforce the importance of initiatives aimed at managerial training and planning.

3.2 Contributions to Theory

The study by Rêgo and Libonati (2025) adds value to the literature by applying the COSO-ERM framework to the context of municipal public health in Brazil, highlighting factors such as managerial profile and socioeconomic conditions and their influence on the adoption of risk management practices (COSO, 2017). Using econometric modeling (such as the Tobit model) and introducing a proxy to measure the level of alignment of practices represent methodological innovations that could underpin future research. If further detailed, this proxy may serve as a reference for evaluating different scenarios and broadening the understanding of how risk management manifests in distinct contexts.

Collecting data from controllers and health secretaries-two central agents in municipal public management-lends legitimacy to the analyses by bringing the results closer to practical reality. However, the literature could be further explored to clarify how the perspectives of these managers complement or diverge from pre-existing studies, thereby reinforcing the importance of integrating theoretical approaches with empirical evidence (de Mendes et al., 2022). In addition, comparisons with other international contexts would help expand the understanding of Brazilian specificities and enhance the theoretical scope of the findings.

Overall, the article contributes by demonstrating the applicability of COSO-ERM in municipal scenarios, showing how adopting risk management practices can strengthen governance and improve the efficiency of resource allocation in the health sector (TCU, 2020). With additional depth regarding the adopted proxy and the analysis of the determinants, the theoretical contributions of the work could be further consolidated, paving the way for studies that investigate other variables and realities, as well as for the development of comparative research that enriches the debate in the accounting and management literature.

3.3 Practical Relevance

Risk management, serving as an instrument of public governance, proves particularly relevant for Brazilian municipalities, which face challenges in managing resources and providing efficient health services (TCU, 2020). The analysis of managers' profiles and educational backgrounds reinforces the need for technical qualification, as better-prepared managers tend to implement risk management practices more effectively. This scenario contributes to the improvement of administrative processes and the strategic allocation of resources, thereby enhancing both efficiency and transparency in municipal management.

The adoption of structured decision-making methods based on evidence and guided by the analysis of socioeconomic factors facilitates the identification of priority areas for intervention. Consequently, it becomes possible to adjust public health policies, promote improvements in operational processes, and strengthen governance. Strengthening public governance, in turn, requires articulating managerial practices coherent with the objectives of transparency and efficiency, especially in the context of financial constraints and regional inequalities (Ribeiro & Zuccoloto, 2014). In this regard, understanding how factors such as indebtedness and municipal infrastructure influence the adoption of COSO-ERM principles becomes fundamental for guiding continuous improvement actions.

In the health sector, applying these concepts is particularly significant, as the analysis of the characteristics of municipalities and their managers provides a basis for enhancing the planning and execution of services (de Mendes et al., 2022). Although the evidence indicates that higher levels of managerial qualification are associated with more aligned practices, there remains room to discuss how to effectively foster this qualification (Mendes & Carvalho, 2022). Simultaneously, examining socioeconomic conditions through practical examples can contribute to strengthening education and governance policies, thereby generating positive impacts on the responsiveness of the local health system.

3.4 Relevant Practical Issues Not Explored in the Article

Although the article by Rêgo and Libonati (2025) presents significant advances by investigating the determinants of alignment with risk management practices in municipal public health, some practical and analytical issues were not fully explored. These aspects could further enhance the applicability of the results and the study’s contribution to managers and policymakers.

The results presented in the article are clear and well-structured, highlighting the relationships between the variables investigated. However, the analysis primarily focuses on describing the findings, whereas a more critical and analytical discussion could add value to the study. For example, the influence of socioeconomic characteristics on alignment with COSO-ERM could be examined in greater detail, considering contextual factors that either enhance or limit this relationship.

Furthermore, it would be interesting to explore more deeply the implications of the results concerning the variability among municipalities in different regions. Including reflections on how specific contexts-such as financial dependence or the level of governance-might moderate the observed effects, contributing to a richer analysis and broadening the understanding of the challenges facing public management in diverse scenarios.

Although the study provides relevant insights into the determinants of alignment with COSO-ERM, the practical implications of the results could be discussed more explicitly. The paper raises important points, such as the relevance of the managers’ profiles and socioeconomic conditions, but it does not delve into how these findings can be applied in day-to-day public management.

For instance, while municipal managers' experience and training are identified as key determinants, the discussion does not explore how municipalities might invest in technical training and the strengthening of managerial competencies to improve adherence to risk management practices. A more detailed analysis of qualification policies, incentives for training, and strategies to attract more qualified managers would be a valuable addition.

The article also identifies characteristics such as indebtedness and financial dependence, which influence alignment with COSO-ERM. Yet, it does not propose specific interventions to mitigate the effects of these constraints. Strategies such as implementing technical support programs for municipalities with greater economic fragility or creating incentives for structured managerial practices could be suggested. Moreover, discussing how managers might use the results to identify and prioritize critical areas for intervention would help connect the study more directly to the practical needs of municipalities.

The Brazilian context exhibits wide regional diversity, which directly affects the administrative and managerial capacities of municipalities. However, the article treats municipalities as a homogeneous group without considering how regional or cultural factors might influence the results. A more detailed discussion of the differences between regions-such as resource availability, infrastructure, and institutional maturity-would enrich the analysis and increase the applicability of the findings.

Finally, the study could further explore the impact of federal or state public policies on alignment with COSO-ERM practices. Training programs, financial incentives, or the integration of sectoral policies could be included in the analysis as elements that facilitate or hinder the adoption of structured managerial practices. This perspective would broaden the scope of the study and highlight how managers can navigate a public policy environment to improve local governance.

3.5 Conclusion

The article by Rêgo and Libonati (2025) offers an important contribution by investigating the factors that influence the alignment with risk management practices in municipal public health, basing its analysis on the COSO-ERM framework (COSO, 2017). This approach underscores the importance of municipalities' managerial profiles and socioeconomic characteristics, broadening both theoretical and practical understanding of public governance.

The research highlights the relevance of managerial training, the strengthening of governance, and the integration of risk management practices within Brazilian municipalities. By proposing a proxy to measure the level of alignment with managerial practices, the study presents a set of possibilities that could enrich future research and stimulate reflections on the interplay between theory, methodology, and results.

Although the article already presents significant advances, there remains room to deepen the discussion regarding the validation of the proposed proxy and its connection with previous studies. A more detailed analysis of the results and their practical implications could enhance the understanding of how the findings are applied in public management, thereby fostering debates about strategies that integrate regional interventions, technical training, and public policies.

Furthermore, Brazil's regional diversity and cultural specificities deserve further reflection, as they can uniquely influence the alignment with COSO-ERM practices across different municipal contexts. This perspective could enrich the analysis and strengthen the connection between the study’s findings and the practical challenges faced by municipalities.

In summary, despite some areas that could be further developed, the study stands as a valuable contribution to the field of risk management and public governance, encouraging essential debates and reflections for improving municipal public health management. By articulating COSO-ERM theory with the complex context of Brazilian public health, the article opens the way for future investigations and the development of more effective and contextualized management practices.

References

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  This is a bilingual text. These commentaries were originally written in Portuguese, published under the DOI https://doi.org/10.1590/1808-057x20242147c.pt
• Article reviewed:
  Rêgo, C. J. F. N., & Libonati, J. J. (2025). Determinants of alignment level with public health risk management under COSO - ERM. Revista Contabilidade & Finanças, 36(spe), e2147. https://doi.org/10.1590/1808-057x20242147.en

Edited by

• Editor-in-Chief:
  Andson Braga de Aguiar

• Associate Editor:
  Cláudio de Araújo Wanderley

Publication Dates

• Publication in this collection
  04 July 2025
• Date of issue
  2025