A. User-Owned Primary Health Cooperatives

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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 II.

A.  USER-OWNED PRIMARY HEALTH CO-OPERATIVES [TYPE 1.1.1]

User-owned health co-operatives are known to exist at present in
the following countries: Bolivia, Brazil, Canada, India, Japan,
Panama, Philippines, Singapore, South Africa, Sri Lanka, Sweden,
United Republic of Tanzania and the United States of America. 
All are of type 1.1.1. but important distinctions can be made
between sub-types.  During the 1970s a sub-type of these
co-operatives operated in Senegal.  During the 1920s and 1930s
such co-operatives operated in Poland and Yugoslavia.  Although
no longer existing information concerning these countries is
included to allow comparison with currently operating enterprises
of this type.  Until 1995 a comprehensive system of user-owned
health co-operatives existed in Israel.  

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

In all but three of these countries, these health co-operatives
were established and currently operate at the primary level as
fully independent enterprises.  Although in some cases the
individuals who founded them, and the majority of members, may
have been drawn from the co-operative management, they are not
organizationally affiliated with any other contemporary
co-operative enterprise or organization.  

In all but one of the countries in which this type of
co-operative exists they are characterized by a relatively
moderate scale of operation of the level defined in Chapter I as
development phase B or, in most cases, C (i.e. in Bolivia,
Canada, India, Panama, Philippines, South Africa, Sri Lanka,
Sweden and the United Republic of Tanzania).  These are treated
together in section (a) below.  Although some of these in the
United States operate at this level, the majority have
diversified into varied and complex enterprises, identified in
the typology as characteristic of phase D.  Members in most cases
constitute only a minority of total users, most of whom are
enroled in enterprise-based health insurance plans with which the
co-operative is affiliated as service-provider.  The total number
of users is frequently in the hundreds of thousand, in contrast
to the thousands more characteristic of the other user-owned
co-operatives.  For these reasons the user-owned health
co-operatives in the United States are treated as a distinct
sub-type in section (b) below.  

     (a)  Relatively small-scale and organizationally simple
          health co-operatives at early or middle phases of
          development [type 1.1.1.1/B and C]

          (i)  Currently operating

In Bolivia a 1985 review reported eight health co-operatives
(presumed to be user-owned) with a total of 440 members.1/  As
part of its Inter-regional Programme, undertaken as a Follow-up
of the World Summit for Social Development, the International
labour Organization has prepared a provisional list of social
services that might be organized on a mutual basis.  This has
been based on experience of ongoing projects undertaken by ILO
in collaboration with the Belgian NGO Wereldsolidarieteit (World
Solidarity: WSM), and on requests received from the governments
of the countries concerned. It includes support to primary health
co-operatives, organized through co-operatives and mutual groups.

The programme could be undertaken in collaboration with the
Confederation of Workers and the Confederacion Latinoamericana
de Cooperativas y Mutuales de Trabajadores (COLACOT).2/ 

In Canada, it was reported that there were 37 health
co-operatives in September 1995 (presumably all were user-owned
health co-operatives of the community health clinic type).  
There were nine in Saskatchewan, four in Manitoba and two in
Alberta (a total of 15 in the Prairie Provinces); two in British
Columbia; seven in Quebec and three in Ontario; and seven in Nova
Scotia and three in Prince Edward Island (a total of 10 in the
Maritime Provinces). In 1992 the 20 health co-operatives which
responded to the annual survey of all co-operative business
enterprises in Canada reported an aggregate membership of
300,000.  They employed 700 persons.3/
   
Prior to the establishment in 1966 of a comprehensive public
health system, various elements of the co-operative movement were
engaged in improving the health of their members and of others
in the communities in which they operated.  Members of the Wheat
Producers Co-operative of Manitoba contributed from their surplus
(20 per cent in the financial year 1944-45) to the health
programme of the Province.  They also contributed to the
establishment of what were described in 1950 as "group hospital
co-operatives", which during the financial year 1945-1946
numbered 271 in rural districts, with a membership of 14,291
families (that is 51,471 participants). The savings and credit
co-operative movement in Ontario and certain consumer-owned
co-operatives in the Maritime Provinces had organized similar
health services. In Vancouver, British Columbia a health
co-operative was set up by members of co-operatives and credit
unions.  Health co-operatives appeared at local level to fill
gaps perceived by groups of citizens. In Saskatchewan they
appeared as a consequence of a doctor's strike in 1962.  In
Manitoba the Co-operative Housing Association identified a
deficiency of health services in an area to the north-west of
Winnipeg and recommended, in collaboration with other
co-operative enterprises, establishment of a health co-operative.

This was set up subsequently as the Nor'West health
co-operative.4/

In February 1994 there were six community health centres in Nova
Scotia but only one was a co-operative - the New Ross Health Co-
operative, which was incorporated in 1987, began operation in
1990 and served a rural community of about 2,500.  It had found
it could not continue to exist on community-based funding alone,
and had applied to participate in a provincial government
programme designed to promote community health centres (but not
necessarily full health co-operatives).  The Tignish Co-operative
Health Centre in Prince Edward Island had in February 1994 a
membership of 1,700. Staff included full and part time doctors,
a public health nurse, pharmacist, dentist and two dental
hygienists. Service and self-help groups operated from the
co-operative, providing foot care and hearing aid clinics, as
well as Alcoholics Anonymous and groups concerned with the
elderly, grief coping and weight loss. It was reported in
February 1994 that a second user-owned co-operative, at
Wellington, Prince Edward Island, was then being established.5/

The Community Health Services Association (Regina) Limited was
founded in 1962 on the initiative of the local community.  In
1995 it had a membership of 4,545, which included both
individuals and families, a total of 11,740 persons. Revenue in
1995 amounted to 2.3 million Canadian dollars, of which the
provincial government of Saskatchewan contributed 1.98 million
as payments for services rendered to persons insured by the
public health system (who were members of the co-operative).  
Emphasis was given to health education and prevention, and
particularly to family health care. A nursing service was
provided for elderly members. Specialists in dermatology,
optometry, minor surgery and physiotherapy, as well as
counselling, laboratory and radiology services were available. 
 All health professionals were salaried employees.  The Community
Health Services (Saskatoon) Association Limited had a membership
of 5,500 individuals and families. The co-operatives at Regina
and Saskatoon have combined with others at Lloydminster, Prince
Albert and Wynyard in the Federation of Health Co-operatives of
Saskatchewan.

In Quebec the experience of community-based and user-
participatory health organizations has been different in some
respects from other provinces. The Provincial Government had from
the 1960s introduced a network of local centres for the provision
of community services (Centres locaux des services
communautaires).  By 1990 there were over 160 such centres, each
run by a community board and with salaried - not fee-for-service
- staff.  Although this network has developed within the public
sector, it has close organizational links to the community,
having integrated in many instances previously existing community
clinics.

Recently in Quebec a user-owned health co-operative was formed
by a community with the dual objective of establishing a practice
which could be filled by doctors and dentists in search of
employment and satisfying the need for a community-based health
service.  This experiment (Coop Vision les gres) was undertaken
by the small community of Sainte-Etienne des gres, with 1,100
residents in the Mauricie region.  Support was provided by the
Mouvement des caisses Desjardins (the province-wide savings and
credit co-operative).  Government approval has been seen by
specialists as most significant as it was the first time that
official recognition had been forthcoming for this type of
co-operative.6/ 

In British Columbia the CU&C Health Services Society provides
group dental, extended health and weekly indemnity plans,
available to members and their families only, and operates one
medical and two dental clinics, open to the general public as
well as to members and their families.7/

In India, a health co-operative movement had existed in the 1920s
and 1930s.  Prior to the Second World War there were a few health
co-operatives in Bengal, Madras, the Punjab. In the Punjab and
in the United Provinces, "Better-living co-operative societies"
provided some of the functions of health co-operatives.8/ 

In Bengal the Yugoslav type of health co-operatives was adopted,
after a study visit made in 1930 (at the suggestion of
Rabindranath Tagore) by the Superintendent of the Village Welfare
Department, as a model for the establishment of similar
co-operatives in the Birbhum district north-west of Calcutta. 
The first three user-owned, community-based, health co-operatives
began to operate in 1932 - there were 12 by 1938, and had formed
there own Union.  Preventive health activities, and mother and
child care were given priority.  The cooperatives employed
doctors on fixed salaries.

In 1914 the first co-operatively organized village anti-malaria
society was established: by 1940 there were 1,089 with 21,728
members.  They undertook such preventive measures as cutting
vegetation, clearing ponds, filling cesspools, promoting
household hygiene, distributing quinine.  Preventive and control
measures against cholera were also undertaken. The pre-existing
Anti-Malaria League was converted into the Central Co-operative
Anti-Malaria Society, which acted as support and promotion
organization for the local co-operatives.  As an extension of
the environmental control activities, support was given to
improvement in horticulture and agriculture. 9/

However, there does not appear to have been much continuity
between the pre-Second World War and post-War movement.The
first of the user-owned health co-operatives operating in 1995
was established in 1960.  By mid-1995 they were located primarily
in the western and southern States of Maharashtra, Goa, Karnataka
and Kerala.  There were 15 in Maharashtra (not including rural
hospitals and dispensaries established by sugar co-operatives in
this State) and 87 in Kerala.10/

Detailed information is available for only two of these.  The
Shushrusha Citizens' Co-operative Hospital Limited in Bombay,
Maharashtra, was the first co-operative hospital to be
established in India.  The concept of a health co-operative was
first suggested in 1960, the co-operative began operations in
1964 and the foundation stone of its hospital was laid in 1966. 
A user-owned health co-operative, it was created by members of
the local community as a means to provide high quality health
care at reasonable cost, as well as to promote health
consciousness more widely in the entire community. Having
overcome two major initial difficulties: finding persons willing
to invest a one thousand rupees membership fee and finding
doctors to provide very low cost services, the co-operative had
in March 1995 a membership of 7,624.  A panel of 70 consultant
doctors provided basic preventive, but also advanced curative and
rehabilitative care, to members and their dependants, but also
to non-members.  The former obtained a discount of 20 per cent
relative to prices charged to non-members: those members aged 70
and older received a discount of 50 per cent.  Members included
a wide range of professionals, who contributed their varied
expertise to the co-operative. Services were provided free to
non-member low-income households in the community, in part
through campaigns for eye and skin disease prevention, early
diagnosis and treatment and in part through a free immunization
centre. The co-operative operated a nurses training school.   A
Maternity and Child Health unit of the co-operative operated in
the suburban town of Vikhroli.11/

In the State of Kerala the main objective of the 87 health co-
operative units (25 hospitals and 62 clinics as of mid-1995) has
been to provide family and child health care. Eight hospitals
specialized in traditional Indian medicine based on the Yajur
Veda and homeopathy: some manufactured homeopathic drugs.  The
establishment of co-operative hospitals had been strongly
supported by the State Government. The largest such co-operative,
the Indira Gandhi Co-operative Hospital founded in 1971 in
Cochin, provided health services to the work forces of major
private and governmental enterprises and to the predominantly
lower income communities where it was located.  It had 3,000
"shareholders" in 1992.12/ 

In his report to the International Co-operative Health and Social
Care Forum held at Manchester, United Kingdom, on 18 September
1995, the Dean of the Shushrusha co-operative hospital noted that
in India provision of health services by the private sector was
still predominantly concentrated in the major urban areas, but
was spreading to "semi-urban and affluent rural areas". 

In Panama in November 1990, after almost two years of weekly
meetings, a group of doctors and clients resident in the
predominantly rural province of Veraguas joined together to
establish the COOPASI user-owned health co-operative.  They did
so in a context which comprised a single overcrowded public
hospital serving a province whose population was 400,000, and
unaffordable private services. The co-operative's members
included both middle income (doctors, teachers, nurses) as well
as lower income (rural workers, peasants) households: in October
1992 they numbered 300. In return for monthly pre-payments
members were able to benefit from emergency hospitalization
service during their first year and full hospital services
thereafter.  A panel of general practitioners and specialist
physicians provided services at agreed fees paid by the
co-operative in the only private hospital in the province. In
addition, doctors who were members of the co-operative gave a 30
per cent discount to other members for services provided in their
own practices. A health education programme, and an education
programme for members in co-operative organization and management
were operated.

In 1992 the co-operative reported that it had plans to establish
a 24 - hour pharmacy.  It was also intended to improve housing
for members and provide better environmental sanitation in the
urban centre in which the co-operative operated. It was planned
also to negotiate an agreement with one of the largest
co-operatives in Panama, the Co-operative of Educators of
Veraguas, whereby hospital benefits would be provided to that
co-operative's 5,000 members.  Purchase of the private hospital
currently used by members was under consideration.13/

In the Philippines, the National Confederation of Co-operatives,
Inc. (NATCCO) was in the process of forming a user-owned health
co-operative. It was being helped by doctors at the Capital
Medical Centre in Quezon City.  Members of other co-operatives
and of non-governmental organizations were being invited to join.
14/

In South Africa it is known that at least one user-owned health
co-operative operates in collaboration with the National Consumer
Co-operative Union in Marshalltown (Phila Health Care
Co-operatives), and that another (possibly several) health
co-operative, also probably user-owned, operates in East London
(Dunkan Health Co-operatives).15/

In Sri Lanka user-owned health co-operatives have developed
within the context of a substantial co-operative movement in
which consumer, credit and savings and agricultural marketing
co-operatives have been well developed for over five decades. 
In September 1995 it was reported that there were 10 in
operation. 

The first co-operative hospital was established as a user-owned
co-operative dispensary at Moolai in the Jaffna region in 1932
by pensioners.  A doctor and two dispensers provided free
services to members. In 1962 the co-operative became a fully
equipped hospital with a surgery, having received a gift of
equipment from Japan. Subsidized and free services were provided
to members with support from the Government. By 1970 membership
had increased to 3,000 and staff to five doctors, ten dispensers
and 42 nurses.

Other co-operative hospitals have been established: at Kurunegala
in 1951, Galle, Gampaha and Kotahena (Colombo) in 1962 and more
recently at Matara.   These were established primarily to provide
services to members of co-operatives operating within local
communities, most of whom are members of co-operatives, and there
is close collaboration between them and other co-operatives.  
For example, the Galle District Co-operative Hospital recently
decided to extend associated membership to members of all other
co-operatives in the District. Fees would be paid by the welfare
section of their co-operatives and recovered in whole or in part
over time from individual members. The President of the Galle
District Co-operative Hospital is also Chairman of the local
Co-operative Thrift and Credit Society (the oldest in Sri Lanka).
The President of the National Co-operative Federation of Sri
Lanka is a member of the Board of Management of the Gampaha
Co-operative Hospital.

All provide services to middle and lower income households.  
Public health services are well developed, and the health
co-operatives are supported financially by the Government.  They
are intended by co-operators in the areas concerned as a
supplement to public services which are considered to be not as
effective as they could be, while private health services are too
expensive. Most co-operatives reduce fees by 50 per cent for
members, while providing services to non-members at full rates. 
Membership of each of the autonomous health co-operatives varies
between about 1,500 and 3,000; beds number between 50 and 100;
most doctors work in government hospitals and provide their
services as part-time consultants: only the Galle Health
Co-operative employs a significant number of doctors full-time. 
A number of multi-purpose co-operatives have also established
their own hospitals: the Nuwara-Eliya, Anuradhapura and Ratnapura
societies. Their facilities were much smaller than those of
health co-operatives themselves.16/

In Sweden discussions on the future of health care, which have
become more frequent during the 1990s, have included co-operative
health care as a possible solution. The Co-operative Institute,
with the support of the co-operative Folksam Insurance Group and
HSB: Riksforbund, the Union of Housing Co-operatives, completed
a report in May 1991 in which it presented a model for
consumer-owned co-operative health care centres: "Medikoop". 
This followed an initial report in October 1990 and a study visit
to health co-operatives in Canada during the period November 1990
- February 1991. The model was intended as one option for
consideration by local government authorities (county councils
and municipalities) in their discussion of new forms of
organizing health care.   

Health co-operatives would provide the services traditionally
provided by local health centres on behalf of local government
authorities within a designated geographical area. However, they
would extend these activities to preventive health care for
members, and they would co-ordinate such services with programmes
of care for the elderly, school health services and the
occupational health services provided by enterprises.  Folksam
and HSB
considered co-operative health care not as an alternative to the
public sector, but rather as a complement to it and an
alternative to private for-profit programmes and facilities, to
whom local government authorities were increasingly contracting
out programmes and services. Co-operatives of this type were
termed "interested parties partnerships", involving both
consumers and producers as well as local government authorities
and other institutions providing funds.  Although most of the
initiatives appears to have been taken by potential users,
potential providers were also involved, and in theory at least
these may be defined as falling within type 1.2.1/1.  In fact
most of those actually in operation are either user- or producer-
owned, and not jointly-owned.  

The interest of HSB reflected the fact that already in the early
1990s it was providing services to local authorities.  The
programmes of housing for elderly persons included in its member-
housing co-operatives had been diversified in order to include
home help and service apartments: from this it was a short step
to provision of primary health care to elderly members.  Many
elderly members of housing co-operatives were interested in its
organization in the form of a co-operative.  Stockholm's local
government authority planned to operate hospitals and nursing
homes in the form of co-operatives: this was already the case of
nursing homes at Vaderkvarnen and Framnas Skolhem.

On the initiative of the municipality of Borlange, the local
housing co-operative, the Folksam insurance co-operative and
local residents, and under the auspices of one authority,
Kopperberg County Council, plans had been drawn up in 1991 for
a consumer-owned health co-operative which might be opened within
a year.   Already in 1992 staff of a number of local government
operated facilities were discussing the establishment of
provider-owned co-operatives for provision of health and dental
as well as support services such as caretaking and janitorial
services.17/

However, the process of decentralization and privatization which
was proposed during the early 1990s, and which included some
experiments, did not proceed further, and achieved rather limited
results, at least in respect to the development of user-owned
health co-operatives.  The primary level co-operative health
centre at Borlange never moved beyond the planning stage.  The
joint "Medicoop" initiative started by Folksam and HSB was
discontinued in 1992.  HSB subsequently chose to proceed alone,
adopting a different organizational model.  This consisted of a
wholly owned HSB subsidiary, in the form of a joint-stock company
('Grannskapservice or "neighbourhood service"), engaged primarily
in provision of home-care for the elderly.   In February 1996 it
employed about 700 persons.18/ 

In the United Republic of Tanzania the ILO, as part of its
programme of support for small industrial co-operatives, is
promoting health protection for informal sector workers through
five co-operatives and other associations formed by them. 19/ 

          (ii) Operating in previous societal circumstances, but
               not at present

This type of user-owned health co-operative appeared during the
1920s in Yugoslavia, where an extensive system was in operation
until it was brought to an end by the Second World War.  It
provided the model for a younger and smaller movement in Poland
where, before the Second World War, there were about 12 health
co-operatives organized on the Yugoslav Model 20/

The best developed of these early systems was that in Yugoslavia,
where in the 1920s and 1930s a substantial health co-operative
movement came into operation.  Here, the first health
co-operative was founded in 1921. In 1923 there were 13
societies, which had formed the previous year a Union of Health
Co-operatives.  By 1938 there were 134.  Of the 125 of these for
which information was available, membership was 65,600
households, representing about 390,000 persons.  They employed
95 doctors, operated 25 nursing homes and a mobile dental clinic.
21/

This system originated after the First World War as a result of
collaboration between the General Federation of Co-operative
Unions, a Serbian doctor (Dr. Kojic) and the delegate of the
Serbian Child Welfare Association of America.  At that time
health conditions were extremely poor.  The movement was based
upon three principles: (a) improvement in health conditions,
particularly in rural areas, requires the understanding and
active support of the community; (b) it is not enough to provide
information and advice, not even through education at school:
certain material conditions must be created as a prerequisite for
sufficiently widespread understanding, including the use of such
necessary articles as means for personal hygiene, medicines,
medical attention - if these are available, improved habits will
develop automatically; and (c) health problems cannot be resolved
in the same way in highly diverse rural environments as they can
be in urban centres.

For these reasons the founders of the movement decided that
health co-operatives were the best organizational means for
attaining their goals.  The decision was strengthened by the fact
that health co-operatives would be able to draw strength from the
traditions, experience and assistance of a broader co-operative
movement already firmly established in rural areas.

The health co-operatives were financed in part by member
contributions.  These were supplemented by a health fund,
constituting a health insurance fund.  Payments into the fund
were in some cases optional: however, by decision of the general
meeting they could be made compulsory.  These were lower in the
large health co-operatives, higher where membership was small. 
The availability of sufficient financial resources made possible
by these funds allowed for provision of health services to
members at lower rates, and maintenance of a relief fund.

Health co-operatives employed doctors and nurses at fixed prices
according to regulations agreed by the Union of Health Co-
operatives, supplemented by a variable salary, decided upon by
members of each individual health co-operative in the context of
local conditions.  Each health co-operative set up a clinic - in
many cases at first these comprised a few rented rooms, a
dispensary, and rooms for seriously ill patients.  Such
facilities were gradually improved: the first fully equipped
clinic ("health house") being established in 1928.  These were
available also to members of all other village co-operatives. 
Services, including drugs, were provided at an estimated one
third the cost of private for-profit provision.

Rural health co-operatives undertook to vaccinate, free of
charge, all inhabitants in the districts in which they operated. 
In some cases they operated day nurseries and preventive
programmes for children.  Village sanitary conditions were
improved - the labour being provided mostly by members
themselves.  Health education was provided; youth and women's
sections were operated; and attention was given to improved
nutrition and agricultural production.   Villages were divided
into groups of houses for each of which a designated person was
responsible for giving preventive health advice, encouraging
improved hygiene, and promoting healthy living.

From 1927 the Government's Central Institute of Hygiene, aware
of the significant contribution of rural health co-operatives,
provided technical and financial support, and established its own
section for health co-operative development.  The Ministry of
Social Affairs and Public Health also assisted the health
co-operative movement.  In 1930 legislation was adopted which
recognized their contribution, freed then from restrictive
legislation, provided permanent financial assistance to the Union
of Health Co-operatives, and authorized them to act in the name
of the Government and as partners of the public health service. 
As such they were entitled to assistance from local
administrations.
  
It is believed that after World War II, and with the
establishment of the socialist centrally planned systems in both
countries, these health co-operatives formed the basis for the
public sector health service in rural areas, and were absorbed
within it.

     (b)  Large-scale diversified health co-operative complexes
          at middle and advanced developmental phases [type
          1.1.1.1/D] 

Only in the United States of America have user-owned health
co-operatives developed to an advanced phase in spite of having