Chapter I -- Typology


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  REVIEW OF NATIONAL EXPERIENCE IN PROMOTING AND SUPPORTING
   THE CONTRIBUTION OF CO-OPERATIVES TO SOCIAL DEVELOPMENT:
 
  CO-OPERATIVE ENTERPRISE IN THE HEALTH AND SOCIAL CARE SECTORS
      A GLOBAL REVIEW AND PROPOSALS FOR POLICY COORDINATION
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CHAPTER I.      TYPOLOGY OF CO-OPERATIVE ENTERPRISES BASED ON THE
                NATURE OF THEIR ENGAGEMENT IN THE HEALTH AND
                SOCIAL CARE SECTOR 


A.   BASIS OF THE TAXONOMIC SYSTEM

The business activities of almost all co-operative enterprises
have an impact upon the health and well-being of their members
and employees and their dependents.  In many cases they have an
impact also on non-member users and other persons in the
communities in which they operate, and, often, even if only
indirectly, on persons elsewhere in national society.  

Some co-operatives are engaged in the health and social care
sector itself, providing health and other relevant insurance, and
health and social care services to their user-members or other
users;  others have an impact through, for example, the
nutritional quality of the foodstuffs they produce, process or
retail; many do so through their concern for the occupational
health of their worker-members and employees; while many of
these, as well as other co-operative enterprises, provide health
insurance coverage to their members or employees.

Many co-operatives engaged in the health sector itself extend the
services they provide to their members or other affiliated users
from curative to both preventive and rehabilitative programmes,
and from there into associated areas of medical social work, and
provision of social care services.  These may be of a preventive
nature, concerned with the promotion of healthy living and
individual well-being within families and communities.  They seek
to identify conditions which may have consequences for social
well-being and health.  Others may be within the rehabilitative
area.

These areas of concern generally extend to situations of social
integration in the sense of the assimilation or acculturation of
individuals, families and communities who are in some sense
different and for this reason disadvantaged and marginalized
within the host community.  This leads into the larger area of
the contribution of co-operative enterprises to the avoidance,
alleviation or overcoming of poverty and all its associated and
resultant conditions.  The review will not extend into these
broader areas, although reference will be made to them to the
extent that they form the context of the narrow focus.  

While the focus of the present paper is that part of the co-
operatively organized sector of the market which is directly
concerned with provision of health and social care services, it
is thought useful to consider this activity within the broader
context of the impact of the entire co-operative movement or
sector upon health and social well-being.  By this means the
actual and potential alliances and operational relationships
between different types of co-operative enterprise in respect to
their total contribution to health and social care may be better
explored, and a strategy proposed which will attempt to make
greater use of the very large possibilities for mutual support
within the wider co-operative movement.

Given the diversity of types of co-operative enterprise involved,
it was thought necessary, before moving to an evaluation of
progress made, and an identification of the areas of possible
further development, to clarify the nature of the relationship
between the activities of the co-operative movement and health
and social well-being.  This will be done by means of a typology
of co-operative enterprises based on the nature of their impact
upon the health and social well-being of the communities in which
they operate.  

Design of a typology based upon characteristics which are
functionally relevant to the goal of achieving health and well-
being for all members, their dependents and their communities
serves to ensure a better understanding of the contribution of
each part of the co-operatively organized sector, and hence the
nature of their actual and potential relationships and the most
effective means of combining their efforts.  It also reduces
confusion, given that there are many distinct types of co-
operative enterprise among those having direct and indirect,
intentional and unintentional impact upon health and well-being,
and particularly given that each of these may have been given
different names in different countries and periods of their
development.

A typology which encompasses all types of co-operatives, that is
the entire co-operatively organized sector of a national society,
but which leads to a focus on health and social care co-
operatives, can be established on the basis of responses to the
following questions:

     (a) do the activities of the co-operative enterprise have
     an impact upon health and social well-being within the
     national society in which it operates ?

     (b) is it the primary or sole purpose of the co-operative
     to have this impact?

     (c) is impact achieved directly, that is by the provision
     of health and/or social care services? or by provision of
     health and related insurance products? or by both
     activities?

     (d) does the co-operative provide only health services, or
     does it combine these with social care services, or does it
     provide social care services only? or does it provide only
     health and related insurance products, or these in
     combination with other types of insurance?

     (e) is the co-operative owned by its users, that is those
     whose health and social well-being is affected?

     (f) if the activities of the co-operative enterprise do not
     include provision of health and social care services or
     insurance, but have an impact upon health, what type of
     activity has such an impact?  Is this the sole or primary
     activity of the co-operative?

     (g) if the activities of the co-operative have no direct
     impact upon health or well-being, do they nevertheless
     include in their business goals the provision of support
     for the operations of co-operatives directly involved (such
     as financial services)?

An initial brief listing of the principal types of co-operative
whose activities contribute to an improvement in health and
social well-being is set out below.  A summary of the taxonomic
system is presented in Figure 1.  The characteristics of each
type and subtype are examined in more detail thereafter.   


B.   SUMMARY LIST OF TYPES OF CO-OPERATIVE ENGAGED 
     IN HEALTH AND SOCIAL CARE

Co-operative enterprises owned by users
---------------------------------------
     *     user-owned health co-operatives, operated as fully
           independent primary level enterprises, and owned and
           directly controlled by their members independently of
           any other of their affiliations with co-operative
           enterprises, for the purposes of obtaining effective
           and affordable health insurance, or health services,
           or both for themselves and their dependants;

     *     user-owned health co-operatives, operated as fully
           independent primary level enterprises and owned and
           directly controlled by their members, but affiliated
           either through simultaneous membership or
           organizational linkages with broad co-operative
           movement;

     *     user-owned health co-operatives, operated as
           autonomous primary enterprises but sponsored by a
           broader co-operative or trade union organization with
           which there are operational linkages and common
           membership;

     *     user-owned health co-operatives, operated as
           autonomous primary enterprises but sponsored by
           provider-owned health (medical) co-operative
           organizations with which there is no common membership
           but close operational linkages;

     *     user-owned comprehensive systems of health and social
           care insurance and service delivery operated as
           specialist subsidiaries of co-operative organizations;

     *     health insurance and services provided by user-owned
           co-operative enterprises in other sectors to members,
           employees and their dependents, as a benefit of
           membership or employment, by means of a specialized
           department or subsidiary enterprise (but not by means
           of an autonomous health co-operative enterprise);

     *     primary level jointly-owned (user- and provider-owned)
           "multi-stakeholder", or "interested parties" health
           co-operatives;

     *     all co-operatives which provide high standards of
           occupational health to worker-members and employees,
           promote improved occupational health by enterprise
           members and safety in the home for individual members,
           and seek to reduce environmental hazards to health in
           the communities where they operate;

     *     user-owned social care co-operatives operated as fully
           independent primary level enterprises and owned and
           directly controlled by their members;

     *     jointly-owned (user- and provider-owned) or "multi-
           stakeholder" or "interested parties" social care co-
           operatives operated as fully independent primary level
           enterprises and owned jointly by users, providers and
           other interested parties;

     *     provider-owned social care primary co-operatives
           established, owned and controlled by groups of
           professional social care providers as a means to enjoy
           satisfactory working conditions, protect their
           economic and professional interests, and satisfy their
           concerns to make available affordable and appropriate
           social care services to sections of the population
           otherwise inadequately served.  Usually membership
           includes also other individual and institutional
           "interested parties", such as representatives of
           organizations of persons needing social care, trade
           unions and local government authorities;

     *     social care services provided by user-owned health co-
           operative enterprises as an extension of their
           preventive and rehabilitative community-based
           services;

     *     social care services provided by user-owned co-
           operative enterprises in other sectors to members,
           employees and their dependents, as a benefit of
           membership or employment, by means of a specialized
           department or subsidiary enterprise (but not by means
           of an autonomous social care co-operative enterprise);

     *     co-operative insurance enterprises, in some cases
           owned and controlled directly by individual policy-
           holders, but more usually indirectly through
           individual membership in other co-operative
           enterprises and organizations which are the owners,
           and providing health insurance, as well as accident,
           disability and life insurance relevant to prevention
           and rehabilitation;

     *     primary level user-owned co-operative pharmacies,
           established by consumers as a special form of retail
           co-operative, but with additional health promotion,
           prevention and education functions; 

     *     pharmacy departments within stores and supermarkets
           operated by consumer-owned retail co-operatives;

     *     secondary level co-operative networks owned by user-
           owned co-operative pharmacies in order to undertake
           bulk purchases, common service and marketing
           functions;

     *     food processing, manufacturing and distribution co-
           operatives owned by retail co-operatives and ensuring
           the supply of nutritionally appropriate and safe foods
           to enterprises;

     *     retail co-operatives providing unadulterated and
           nutritionally correct foods at affordable prices, as
           well as consumer education services to members, other
           customers and the communities in which they operate;

     *     housing and community development co-operatives
           providing utilities, sanitation, consumer protection
           advice, preventive health and health education,
           rehabilitation and social care;

     *     environmental management, sanitation and cleaning co-
           operatives contributing to health through an improved
           built environment;

     *     financial co-operatives (savings and credit co-
           operatives ("credit unions") and co-operative banks)
           assisting individuals with financial management,
           thereby reducing stress and helping them meet costs
of
           shelter, nutrition, health and social care;

     *     financial co-operatives (savings and credit co-
           operatives ("credit unions") and co-operative banks)
           supplying affordable capital to health and social care
           sectors co-operative enterprises;

     *     co-operative research and development organizations
           engaged in policy development and improvement in
           operational efficiency in the health and social care
           sectors;

     *     co-operative media enterprises, and media facilities
           operated by other co-operatives, diffusing information
           on health, nutrition and social care;

     *     co-operative education enterprises providing
           professional, managerial and administrative training
           in the health and social care sectors;

Co-operative enterprises owned by individual providers
------------------------------------------------------
     *     primary level provider-owned health co-operatives,
           established, owned and controlled by groups of health
           professionals, but in some cases dentists, nurses or
           medical technicians, usually doctors, as a means to
           enjoy satisfactory working conditions, protect their
           economic and professional interests, and satisfy their
           concerns to make available affordable and appropriate
           health services to sections of the population
           otherwise inadequately served;

     *     health insurance and services provided by provider-
           owned co-operative enterprises in other sectors to
           members, employees and their dependents, as a benefit
           of membership or employment, but means of a
           specialized department or subsidiary enterprise (but
           not by means of an autonomous health co-operative
           enterprise);

     *     social care services provided by provider-owned co-
           operative enterprises in other sectors to members,
           employees and their dependents, as a benefit of
           membership or employment, by means of a specialized
           department or subsidiary enterprise (but not by means
           of an autonomous social care co-operative enterprise);

     *     worker-owned labour-contracting co-operatives in
           health and social care sectors providing, for example,
           building maintenance, catering, cleaning, security,
or
           parking supervision services, or acting as employment
           agencies for members (i.e. providing labour directly
           within sector facilities, as a complement to their own
           labour force);

     *     worker-owned primary level health and social care
           sector supply co-operatives, whose members constitute
           the work-force and which either manufacture special
           inputs (medical equipment, special furniture, etc) or
           supply services (ambulance drivers, accountants,
           lawyers, facility architects and equipment designers,
           etc.); (i.e. providing goods and services created by
           application of labour outside sector facilities);

     *     secondary level co-operative networks owned by primary
           level worker-owned health and social care sector
           support co-operatives;

Co-operative enterprises owned by non-co-operative enterprise
-------------------------------------------------------------
     *     secondary health services delivery co-operatives owned
           by groups of non-co-operative enterprises;

     *     secondary level provider-owned health co-operative
           networks owned by independent self-employed health
           providers (doctors' or dentists' solo- and group-
           practices);

     *     secondary health insurance purchasing co-operatives
           owned by non-co-operative enterprises;

     *     secondary level co-operative networks owned by
           independent for-profit pharmacies, set up in order to
           undertake bulk purchasing, common service and
           marketing functions; 

     *     enterprise user-owned secondary level health sector
           support co-operatives, owned by facilities such as
           hospitals and clinics (in public, co-operative,
           private for-profit and private not-for-profit sectors)
           for the purpose of making bulk purchases and providing
           common services such as financial and personnel
           management, specialist medical services, temporary
           staff administration, legal services and insurance;

     *     agricultural and fisheries purchasing and marketing
           co-operatives owned by independent producers, and
           primary producer co-operatives in agriculture and
           fisheries processing and marketing nutritionally
           appropriate and safe foods;

The types of co-operative are listed above in three groups: those
owned by consumers (users, clients or beneficiaries); those owned
by workers (providers or producers); and these owned by
enterprises, including for-profit firms.  In the remainder of the
chapter, however, these types are organized into groups according
to the extent to which their business goals are concerned with
health and social care.  


C.   CO-OPERATIVE ENTERPRISES WHOSE BUSINESS GOALS ARE
     SOLELY CONCERNED WITH HEALTH AND SOCIAL CARE

This type includes co-operative enterprises whose original and
current sole or primary function is to provide either health or
social care services, or both, to users.  A basic distinction is
made between co-operatives primarily providing health services,
but which in some cases also provide social care services, and
those co-operatives providing social care services (none of which
also provide health services).  

     [1.1]      Co-operative enterprises providing health
                services to individuals (health co-operatives)

A distinction is made between a first group of health co-
operatives, which are user-owned, a second group which are owned
jointly by users and providers of health services, and a third
group owned by providers only.

The terminology used in respect to co-operatives of this type
varies between countries and organizations, and over time.  There
is some tendency in English-language usage to refer to user-owned
co-operatives as "health co-operatives" and to those which are
provider-owned as "medical co-operatives".   This would imply
that the intermediate group would be termed "joint health/medical
co-operatives". User-owned preference for "health" and provider-
owned preference for "medical" may have developed at a time when
user-owned enterprises were engaged in health maintenance, in
contrast to provider-owned enterprises, which were concerned very
largely with curative, and to some extent rehabilitative
services, which might be termed "medical".  However, there has
been a trend toward the latter type adding a substantial
preventive component, including concern for broad programmes of
"healthy living", implying that medical interventions are only
one among several valid approaches to achievement of health. 
Consequently, the broader term "health co-operative" appears to
be appropriate even in the case of provider-owned co-operatives
engaged in the health sector.   

The Brazilian provider-owned health co-operative system, Unimed,
refers to itself in English translation as the National
Confederation of Health-care Co-operatives.  User-owned co-
operatives have had a similar emphasis upon broad preventive
approaches for an even longer period, so that the term "health
co-operative" has always been particularly appropriate for them. 
It should be noted, however, that for purposes of translation
into English, the Japanese consumer co-operative movement prefers
to use the term "medical co-op" or "medical-health" co-operatives
for user-owned enterprises.  In view of this convergence of
emphases, use of the term "health co-operative" appears to be the
most appropriate as a general description of this type of co-
operative enterprise, and will be adopted in this review.  

Use of the term "health co-operative" to include both user-owned
and provider-owned enterprises has been acknowledged very
recently by the co-operative movement itself.   The Draft Rules
of the International Health Co-operative Organization, adopted
in January 1996 by a Steering Committee responsible for setting
up this specialized body of ICA, describe the Organization as "a
forum for consumer and producer health co-operatives".   These
are described as "co-operative organizations which ... have as
their main or partial objective the provision of health care to
their members or the provision of self-employment for health
professionals".

However, some variety in English-language terminology still
exists.  In some countries the term which has been used is
"health care co-operative" (or "dental care co-operative").  In
Saskatchewan, Canada, individual user-owned health co-operatives
are referred to as "community health service associations", but
the secondary organization in Saskatchewan which brings together
five such associations has the name "Federation of Health Co-
operatives". In British Columbia a similar user-owned health co-
operative is termed a "health services society".   In India and
Sri Lanka such co-operatives are often termed "hospital co-
operatives". In Sweden a proposed model for a community-based but
user-owned health co-operative was termed a "Medikoop" (in
Swedish).

In the United States a number of user-owned health co-operatives
describe themselves as "group health co-operatives" or "group
health associations". Others term themselves "community health
centres".   Because they combine service delivery with a health
insurance system (or "plan") some are termed "group health plans"
or "family health plans", "metropolitan health plans" or
"community health plans", or "health insurance plans".   A few
are termed "family health plan co-operative".   Generically, they
are designated "health maintenance organizations (HMOs)", with
the qualification that they are co-operatively organized, as
distinct from other types of HMO, which may be not-for-profit
(but not co-operatively organized) or for-profit enterprises. 
However, only a few term themselves "co-operative health
maintenance organization", or "group health co-operative health
maintenance organization".  Some user-owned health co-operatives
have names which give no indication of their co-operative
character - for example, "Health Partners".  In the United States
the term "health cooperative" has been applied also to a
secondary purchasing, supply and service network owned by
independent hospitals.

Provider-owned co-operatives refer to themselves variously as
"co-operative health clinics", "hospital and health services co-
operative", or "general practitioners'/doctors'/specialists', co-
operative".

Social care co-operatives frequently designate themselves on the
basis of function - e.g. child-care co-operatives, nursery co-
operatives, pre-school co-operatives, co-operative creches, home
care co-operatives, co-operative residences/residential co-
operatives, nursing home co-operatives, disabled persons special
workplace co-operative, sheltered work-place co-operatives,
rehabilitation co-operatives.  In Italy a distinction is made
between "social care" co-operatives and "social employment" co-
operatives, the latter being the equivalent of sheltered workshop
co-operatives.   A small proportion of "social care" co-
operatives in fact specialize in health service delivery.

Some variety in terminology exists also in French and Spanish. 
In French a comprehensive review of both user- and provider-owned
co-operatives in eleven countries terms them "cooperatives de
sante".  A system of distinct but affiliated provider-owned and
user-owned co-operatives in Spain has been termed in French "le
complexe cooperatif de soins de sante".   Social co-operatives
are termed simply "cooperatives sociales", or "cooperative
d'initiative sociale"

In Spain a specific provider-owned health co-operative has been
designated "autogestio sanitaria". A hospital co-operative has
been designated "Sociedad Cooperativa de Instalaciones
Asistenciales Sanitarias". In discussion of the topic, although
not as a designation of an actual co-operative enterprise in the
health sector, the term "cooperativa de salud" has been used.  
The entire area of co-operative engagement in the health sector
is termed "cooperativismo sanitario".  When referring to the
movement which has brought into close association provider-owned
and user-owned enterprises, the term "cooperativismo sanitario
integral" has been used.

In some countries, particularly those formerly socialist
countries where health and social security systems were closely
associated with enterprise-based eligibility, the term "medical
co-operative" is the term in English translation used by the
organizations themselves to refer to the health services
department of a co-operative enterprise or larger co-operative
organizations.    

     [1.1.1]    User-owned health co-operatives

     [1.1.1.1]  User-owned health co-operatives operated as fully
                independent primary enterprises not affiliated
                with any other co-operative enterprise or
                organization

This basic type of user-owned health co-operative is a fully
autonomous enterprise operating at the primary level.  It is
owned and directly controlled by its members who, in establishing
or maintaining their co-operative, do so independently of any
other affiliation they may have simultaneously with another co-
operative enterprise or organization.  Its original primary
business goals (and usually its only goals) are to maintain the
health status of members and their dependents, if this is already
satisfactory, or to improve that status, if not yet satisfactory.

The co-operative is an organizational means whereby the group of
individuals who are its members empower themselves in respect to
both environmental processes relevant to their health, and to
other institutions engaged in the health sector.  Members, who
are the owners as well as the actual or potential users or
clients of the enterprise, may represent themselves alone or,
additionally, members of their families, households or other
dependents within a wider support system.

This type of health co-operative combines health insurance and
service delivery functions: they manage their own autonomous
health insurance fund (or "plan", in the United States), and they
deliver directly at least part of the total of services they
require in order to maintain their health, or to recover it when
ill.  

In the United States this type of health co-operative is
considered to be one sub-type (that which is co-operatively
organized) of enterprises termed "health maintenance
organizations" (HMOs), some of which are not-for-profit, other
for-profit enterprises.  

Principal variants of this basic type can be identified in terms
of organizational structure and operational processes, both of
which are closely related to phases in their development over
time. It seems possible to distil from the actual experience of
this type of health co-operative what might be described as a
"normal" developmental trajectory, as part of which both function
and organization change. Naturally there are numerous variants
of this trajectory and each existing user-owned health co-
operative has had its own unique experience and hence character.

The following are the principal developmental phases defined in
terms of activities and organization structure:

[phase A]  Use of collective self-help activities without
           external resources; actions on the natural and built
           environment as preventive measures; pooling of
           indigenous experience and knowledge, including
           particularly that held by specialists (for example,
           indigenous physicians and midwives); pooling of
           internal labour in order to provide curative or
           rehabilitative care, including collection and
           processing of indigenous drugs, special foods and
           other materials;  and pooling of resources, financial
           and in kind, as an insurance against conditions of
           individual ill-health and/or disability. [type
           1.1.1.1/A]

[phase B]  Use of combined resource (member shares, fixed pre-
           payments), predominantly financial, but in difficult
           conditions also in kind, in order to constitute a