Progress Toward a Co-operative Health and Social Care Sector

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   This document has been made available in electronic format
           by the International Co-operative Alliance.
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       International Day of Co-operatives, 6 July 1996

                                             Background Note #4
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  Progress Toward a Co-operative Health and Social Care Sector
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An important recent development within the international
co-operative movement has been the appearance of new co-operative
enterprises in the health and social care sector.  Co-operative
expansion here brings the concept of a co-operative form of
organization into an area of vital concern to most citizens and
governments.  It is an area of particular interest to women,
whose more extensive engagement in the co-operative movement will
be a major source of its future strength.

The United Nations Department for Policy Coordination and
Sustainable Development, in close collaboration with ICA, has
recently completed a global review of co-operative enterprise in
this sector.  It concluded that the movement has a very
considerable potential as a fully comprehensive alternative to
both public and private for-profit activity in this sector.

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Components of a co-operative health and social care sector
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Direct Activity

*    providing social security, including health, accident and
     disability insurance, as well as protection against other
     risks: co-operative insurance enterprises, insurance
     departments of broader co-operative organizations and
     combined health insurance and service delivery
     co-operatives, all owned by user-members directly, or
     through membership of other co-operatives;

*    delivering health and social care services to members, and
     in some cases to others in the same communities, with a
     strong emphasis upon broad prevention, but with full
     provision for curative and rehabilitative coverage:
     user-owned health co-operatives, user-owned combined health
     insurance and service delivery co-operatives, user-owned
     social care co-operatives, and user-owned combined health
     and social care co-operatives.  These might be autonomous,
     or affiliated with other co-operatives;

*    purchasing or providing insurance and delivering health and
     social care services, including occupational health, as a
     benefit of membership or employment: co-operative
     enterprises and organizations in all other sectors;

*    also delivering health and social care services to
     individuals: joint user- and provider-owned and fully
     provider-owned health and social care co-operatives;

*    supplying medicines and medical equipment: co-operative
     pharmacies operating as autonomous specialized
     consumer-owned retail co-operatives, or as specialized
     departments of general consumer-owned retail co-operatives;

*    providing nutritionally appropriate food, safe household
     equipment and adequate clothing: retail co-operatives;

*    providing healthy and socially integrative shelter and
     neighbourhoods, water, sanitation and other utilities:
     housing and community development and utilities
     co-operatives;

*    ensuring healthy environments in neighbourhoods, homes and
     places of employment: labour contracting and
     service-providing sanitation and cleaning co-operatives;

*    facilitating management of individual and enterprise
     finances, thereby reducing pressures upon health and social
     cohesion: savings and credit co-operatives ("credit
     unions"), co-operative banks and co-operative insurance
     enterprises;

*    diffusing information on 'healthy living', social
     relationships, insurance and use of co-operative health and
     social care enterprises: co-operative media enterprises and
     media departments of all co-operative enterprises.

Indirect Support Activity

*    manufacturing and supplying goods and services: input
     purchasing, common service and marketing co-operatives
     owned by groups of co-operatives in the health and social
     care sector;

*    supplying supplementary labour and services to health and
     social care co-operatives: specialist labour-contracting
     and service co-operatives in such areas as ambulance
     services, cleaning, catering and security, data processing
     and accounting;

*    supplying nutritionally appropriate food to retail
     co-operatives and institutions operated by health and
     social care co-operatives: primary sector production
     co-operatives and input supply, extension and marketing
     co-operatives;

*    supplying safe equipment and infrastructure: manufacturing
     and utilities co-operatives;

*    providing education and training of professional,
     para-professional, managerial, administrative and support
     personnel: specialized and general education and training
     co-operatives;

*    diffusing information on co-operative enterprise in health
     and social care: co-operative media enterprises and media
     departments of all other co-operative enterprises;

*    financing co-operative engagement in health and social
     care: co-operative banks and savings and credit
     co-operatives;

*    supporting enterprise operation and systems development:
     general and specialized co-operative research and
     development institutions;

*    promoting development and operation of comprehensive
     co-operative systems: co-operative health and social sector
     apex organizations. 

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      Current direct provision of health and social care
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User-owned health co-operatives exist in Bolivia, Brazil, Canada,
India, Japan, Panama, Philippines, Senegal, Singapore, South
Africa, Sri Lanka, Sweden, the United Republic of Tanzania and
the United States. About 39,000,000 members and their dependants
obtain health insurance and services from them.

Provider-owned health co-operatives operate in Argentina, Benin,
Bolivia, Brazil, Chile, Colombia, Costa Rica, Germany, India,
Italy, Malaysia, Mongolia, Paraguay, Philippines, Poland,
Portugal, Spain, Sweden, the United Kingdom and the United
States.  About 13,000,000 persons have contracts with them, but
most also serve other members of the public.

Many health co-operatives provide social care as an extension of
their preventive and rehabilitative programmes. But there are
numerous autonomous social care co-operatives in the same and
other countries.

Health insurance is offered by 19 of the 72 co-operative
insurance enterprises' members of the International Co-operative
and Mutual Insurance Federation (ICMIF). They operate in 15
countries: Belgium, Canada, Colombia, Denmark, Ecuador, Germany,
Italy, Japan, Malaysia, Peru, Republic of Korea, Singapore,
Spain, the United Kingdom and the United States, including
separately in Puerto Rico.

Pharmacy services are provided by many health co-operatives; by
other co-operatives for their members, employees and their
dependants; by general retail co-operatives; and by specialist
consumer-owned pharmacies. In Europe about 2,500 of the latter
serve 30,000,000 members and have 10 per cent of the market.

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      Determinants of successful co-operative enterprise
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The United Nations study identified the principal determinants
of successful co-operative enterprise in this sector: (a) extent
of formal public sector responsibility and effectiveness; (b)
nature of the legal and administrative environment determined by
perceptions held by legislators, ministers and officials; (c)
pressures upon policy-makers from other stakeholders (citizens,
co-operators, trade unionists, members of other social movements,
health and social care professionals and representatives of the
private for-profit sector), each holding their own perceptions;
(d) availability of the catalytic energies of a small number of
particularly committed individuals; and (e) availability of
support by the broader co-operative and other social movements.

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      Trends toward comprehensive and integrated systems
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During the last decade operational alliances have been created
between co-operative insurers, health co-operatives, co-operative
pharmacies, and co-operatives seeking to provide benefits to
their members and employees (in Colombia, Italy and Malaysia). 
Elsewhere, and particularly in Brazil, integrated complexes have
developed which include a wide range of specialist subsidiaries. 
In a few countries (notably in Belgium, Italy, Japan, Portugal,
and the United States) national apex organizations have been set
up by certain of the types of co-operative in this sector.

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          Progress toward international collaboration
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Contacts between individual co-operatives are increasing.  The
European Committee of Workers' Co-operatives (CECOP) has a
Department of Social Co-operatives, active in promoting
provider-owned enterprises.  The International Co-operative and
Mutual Insurance Federation (ICMIF) has set up an Insurance
Intelligence Group, one of whose current tasks is to explore the
possibilities of further expansion in provision of health
insurance.

Following two regional and two global meetings held between 1992
and 1995 good progress has been made toward setting up as a new
specialized body of ICA an International Health Co-operative
Organization.   Membership would comprise co-operative
organizations affiliated directly or indirectly to ICA which has
as their main or partial objective provision of health care to
their members or the provision of self-employment for health
professionals.   Educational and research institutions which
promoted health co-operatives or related services were also
eligible. 

Interest shown by governments and intergovernmental agencies
In most countries further expansion of co-operatively organized
activity must involve some kind of relationship, and preferably
formal partnerships between co-operative and public sectors. 
Steps have been taken in this direction in a number of countries,
notably Canada, Costa Rica, India, Sri Lanka, Sweden and the
United Kingdom.  Developments have been followed with interest
by intergovernmental organizations, including the UN, ILO, WHO,
UNDP, UNESCO, the World Bank and the European Union. 

The global review will be published by the United Nations later
in 1996 and can be ordered from official distributors in all
countries.  ICA will include an advance unedited version on the
Internet at gopher://wiscinfo.wisc.edu:70/11/.info-source/.coop.