Chapter IV -- Other Co-ops Contributing to Health and Social Care



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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 IV.    DEVELOPMENTAL DYNAMICS AND CONTEMPORARY GLOBAL
               SITUATION OF CO-OPERATIVE ENTERPRISES WHOSE
               BUSINESS GOALS ARE NOT PRIMARILY CONCERNED WITH,
               BUT INCLUDE HEALTH AND SOCIAL CARE

Co-operative business enterprises whose principal activity is to
provide services or supply commodities directly to the health
sector have been identified as "Health and Social Care Sector
Support Co-operatives".  However, many other producer-  and
service provider-owned worker co-operatives, including labour co-
operatives, may supply a variety of goods and services to a range
of customers, only some of whom are enterprises in the health
sector.  Others supply goods and services to households which are
of significance to the maintenance by individuals of healthy
living, or of a capacity for providing their own health and
social care (nutrition, safe water, sanitation, shelter,
clothing, etc.).  No attempt will be made here to summarize the
diverse and widespread activities of co-operatives throughout the
world.  Nevertheless, some examples are of interest to the theme
of the review: that is that many components of the international
co-operative movement contribute to health and social care.  The
examples of interest to the theme of the review: that many
components of the international co-operative movement contribute
to health and social care, are intended as illustrations.  They
were chosen from the available literature, and should not be
considered to be the selected results of a comprehensive review. 

     A.   CO-OPERATIVES IN PRIMARY PRODUCTION [TYPE 2.1]

Co-operative organization of the production of foodstuffs is
substantial in a number of countries. Although agricultural and
fisheries production co-operatives are not of major significance,
group purchasing, common service and marketing (including
processing) co-operatives owned by independent agricultural
producers, and by independent fisheries enterprises, are of major
importance in many developed countries, and are significant also
in a number of developing countries. In Europe, Canada and Japan,
for example, such co-operatives account for over half of inputs
to agricultural production, and for over half of the processing
and marketing of products.

Because their business goals and practices are established and
controlled by members who are aware of the long-term impact upon
themselves, their families and their communities of imbalances
between human society and the natural environment, these types
of co-operatives have taken the lead in a number of countries in
supporting attempts by producers to adopt and practice
environmentally appropriate and sustainable methods.  These have
included the production, processing and marketing of safe
foodstuffs, including organic products.  They have taken the lead
also in safeguarding occupational health in primary production.

During the last decade an increasing number of these co-
operatives, as a response to the demand of members, have begun
to promote, support and facilitate adjustment in the production
methods of members toward greater sustainability. In some cases
entire national co-operative movements in these sectors have
adopted strategies for sustainable development, generally
supportive of healthier life-styles. For example, the Japanese
National Federation of Agricultural Co-operative Associations
(ZEN-NOH), inaugurated a comprehensive environmental action plan
in 1992. 141/ In 1991 the Israeli Organization of Agricultural
Co-operatives reported that its members were becoming more aware
of the need to change to sustainable agriculture.142/

These  and other movements have given particular attention to
organic agriculture and the supply of safe and nutritionally
appropriate foods: often they have worked closely with consumer
co-operatives to this end - such alliances are well developed in
Denmark 143/, Hungary 144/, Japan 145/, Switzerland 146/ and the
United Kingdom. 147/  

     B.   CO-OPERATIVES IN SECONDARY PROCESSING AND
          MANUFACTURING [TYPE 2.2]

Co-operative enterprises in the secondary sector, including those
in manufacturing, construction, transportation and utilities
contribute significantly and in a number of ways to improved
health.  Their attention to occupational safety is central to
their business practices, given that a significant proportion of
their labour force comprises owner-members, while provision of
training to both members and employees so they can contribute
effectively to the development of their co-operatives - part of
one of the principles of the international co-operative movement
- has meant the extension of concern for occupational health to
non-member employees.

Many co-operative enterprises in the secondary sector are engaged
in food processing, either as subsidiaries of primary production
marketing co-operatives, or of wholesale and retail distribution
co-operatives, or as worker-owned primary co-operatives.   In
many countries, such enterprises have assumed a leading role in
seeking manufacturing processes which protect the nutritional
value of foodstuffs.  Although many of the worker-owned co-
operatives operate at a small scale, they have been innovators
and industry leaders in these areas.

     C.  RETAIL DISTRIBUTION CO-OPERATIVES [TYPE 2.3.1]

     1.   In respect to improved nutrition, household safety and
          healthy living

Consumer-owned wholesale and retail co-operatives, which supply
households with foodstuffs and household equipment, occupy
substantial shares of the market in many countries.  In December
1991, for example, in the then European Community, together with
the Nordic Countries, Switzerland and the then Czechoslovakia,
a total of 21.6 million households were members (approximately
60-65 million persons).  Over half of retail food sales in
Switzerland, 34 per cent in Denmark and 30 per cent in Finland
were made by consumer-owned retail co-operatives.  In Japan in
1994 26 per cent of households were members of the consumer co-
operative movement.

As co-operative enterprises which are owned and controlled by the
users of the goods and services they supply they have been always
concerned to supply them with high quality and affordable
products.  Indeed, some of the earliest co-operative enterprises,
including that set up by the founders of the modern co-operative
movement, the Rochdale Pioneers, were established precisely for
the purpose of supplying their members with "pure and
unadulterated goods". During recent decades in a number of
countries this type of co-operative has taken the lead in
ensuring that foods supplied to members were safe and
nutritionally appropriate, and in providing to their consumer
members education and information on nutrition, household safety
and preventive health.  Consumer co-operative movements perceive
these concerns to be part of their overall goal of persuading
societies to adjust life-styles radically in order to achieve
environmental protection, societal sustainability, and individual
health. 

Co-operative movements of this type are particularly well
developed in Europe and Japan. Most have adopted energetic and
innovative programmes, concerning which only a few illustrations
can be included.  For example, the consumer co-operative movement
in Sweden adopted a programme for the environment in May 1990
which viewed environmental, health and ethical matters to be
interlinked and essential components.  The movement had taken
their impact on health into account in developing its own
schedule of products for several decades previously: for example,
it had been selling new types of detergents for use by persons
having allergy problems since the 1960s. 148/  In the United
Kingdom the Co-operative Wholesale Society Ltd. led the branch
during the mid-1980s towards clearer labelling of nutritional
information on all food products.  It has campaigned vigorously
for a number of years for members to adopt a "healthy eating"
life-style.  In 1995 it issued a major report, "The Plate of the
Nation", which highlighted problems of diet in the country.  They
are also a number of smaller worker-owned health food wholesale
co-operatives: for example the SUMA co-operative in West
Yorkshire, which had in 1995 60 workers, 50 of whom members.149/ 
The Japanese consumer co-operative movement has concluded
agreements with the agricultural co-operative movement to ensure
supply of safe foods, which it ensures are properly packaged and
labelled. 150/  In western Canada, Federated Co-operatives Ltd.,
which serves as a central supplier to 330 consumer co-operatives,
introduced in 1992 a programme called "Responsible Choices",
designed to provide all member households information on the
extent to which goods on the market were compatible with human
health. 151/ 

Because of their market shares, consumer co-operatives are able
to put pressure on agricultural producers. In Denmark, for
example, the market they provide for organic foodstuffs (even
though sold at a higher price than non-organic products) has
encouraged farmers to respond, so that by 1990 one quarter of
milk sold by retail co-operatives originated from farms which did
not use industrial fertilizers or chemical pesticides. 152/ 
Leverage of this nature is increased by the fact that most
consumer co-operative movements have their own manufacturing and
processing plants, and even their own production units in some
cases.  For example, in the United Kingdom, the Co-operative
Wholesale Society Ltd. runs a 150 acre experimental organic form
at Stoughton Grange.153/

     2.   In respect to distribution of medicines and medical
          equipment

In the United Kingdom, fourteen consumer-owned retail co-
operative societies operate pharmacies of their own, some in
conjunction with an optical service.  These societies have 228
outlets and their pharmacy/optical turnover during 1995 services
amounted to 84 million pounds. 154/ In Singapore the co-operative
supermarket chain operated by the National Trade Union Council
includes a chain of co-operative pharmacies.155/

     3.  In respect to social care

In Japan the consumer-owned retail co-operative movement has
begun to provide its own services to elderly members.  For
example, Co-operative Kanagawa, after a visit in 1990 to the Co-
operative Home Care Associates in New York, which is a home-care
provider-owned co-operative, sponsored a similar home-care
programme.  As a result of its success a considerable number of
autonomous worker-owned co-operatives were set up to provide home
care to elderly members of Co-operative Kanagawa, and the
approach was spreading to other parts of Japan.156/.    

In Switzerland the Migros Co-operative Federation established a
department in 1977 whose purpose was to help elderly members
maintain and expand their capacity to enjoy an active and healthy
life with the maximum degree of self-reliance and continued
participation in, and contribution to, their communities. 
Consequently, programmes were designed to build and maintain all
physical, mental and social faculties.  They may be considered
types of broad preventive programme.

Among programmes of this type were memory training sessions,
conducted in a socially supportive environment; holiday camps
with specially designed programmes for the development of
faculties; and pre-retirement programmes for retiring employees
and their dependants. Many programmes were managed through the
Migros Clubs and Schools associated with each retail store.157/

The other major Swiss retail co-operative organization, Co-op
Suisse, operated similar programmes, although addressed more
specifically to the needs of elderly women. These were one part
of the programmes of its Women's Guild, founded in 1922, and
organized in entirely autonomous local groups throughout the
country. The programmes were also broadly preventive, and include
short courses on retirement age living, productive and satisfying
use of spare time, maintenance of confidence and self-esteem,
physical exercise and sport, health care and widowhood.   A
solidarity fund was available in cases of emergency, and legal
advice, including free legal counsel in special circumstances,
was provided.  Funding was provided in part by user-fees, in part
by subsidies from the parent co-operative organization and from
Swiss co-operative insurance enterprises and banks.158/

     4.   In respect to funeral services

In some countries, such as the United Kingdom, the consumer-owned
retail co-operative movement has included provision of funeral
services as one among the set of services provided to all
members.  Here, 25 consumer-owned co-operative societies provide
funeral services.  Their turnover in 1995 amounted to 200 million
pounds sterling.  A developing aspect of this business is a
facility to provide for the expense of a funeral at a fixed rate
during the lifetime of the member.  The co-operative share of the
funeral market in the United Kingdom is about 25 per cent.159/

     D.  FUNERAL CO-OPERATIVES [TYPE 2.3.2]

Forms of mutual savings or insurance against the costs of funeral
services have been widespread in many societies: one of the
original purposes of the early "friendly societies", the
precursors of modern co-operative insurance enterprise, was in
fact to meet burial costs.  To this purpose has been added in
some cases the co-operative ownership of undertaking enterprises
and burial plots.  By means of co-operative organization costs
could be reduced, compared to private for-profit enterprise, and
the financial and emotional stress felt particularly by the
elderly can be reduced.

Independent funeral co-operatives are well developed in certain
areas of Canada. In 1993, in provinces other than Quebec, there
were 34 funeral co-operatives with a total membership of 105,000. 
In the Evangeline district of Prince Edward Island in the late
1980s about 800 members provided the voluntary work-force and
were the eventual consumers of the services provided.  The co-
operative was financed in part by member shares, in part by a
loan from the savings and credit co-operative, whose membership
largely overlapped with that of the funeral co-operative.  It was
hoped that if similar funeral co-operatives were established in
neighbouring communities, common services and training could be
jointly arranged. 160/

In Quebec there were in 1995 30 funeral co-operatives with a
membership of 130,000 and an annual turn-over of $ CAN
10,000,000. In certain regions of the Province they had over 25
per cent of the local market.  Their objectives were to reduce
the financial stress and anxiety experienced by elderly persons
and their relatives. 161/

In the United States, in order to avoid the often high costs of
private for-profit funeral services individuals in many
communities have set up funeral co-operatives.  In 1994 it was
estimated, for example, that average costs for funeral and burial
were US $ 5,000, whereas the Chicago Memorial Association offered
basic funerals for US $ 950 and cremations for less than $ 400. 

In addition, user-owned associations known as "memorial
societies" do not act as undertakers themselves, but are member-
owned nonprofit groups that renegotiate the prices of services
with collaborating funeral providers on behalf of their members
through group purchases of funeral and burial services. In 1994
there were 147 such memorial societies in 40 of the States in the
United States, with an estimated total membership of 500,000
persons. Only some of these associations organized themselves as
formal co-operatives. These associations had established a
national tertiary organization, the Continental Association of
Funeral and Memorial Societies with headquarters in Wisconsin,
within a region of strong co-operative movement development.162/ 

In Colombia over one hundred co-operatives, trade unions, mutual
societies and parent's associations have established a secondary
funeral co-operative "Coopserfun", which by the late 1980s in
Bogota had become the third largest provider of funeral services. 
It was established because of the monopolistic organization of
private for-profit funeral services.163/ 

     E.   CO-OPERATIVE INSURANCE ENTERPRISES [TYPE 2.3.3]

     1.   In respect to general insurance

Co-operative insurance enterprises are in operation in 35
countries.  They contribute both indirectly and directly to the
health of their members and dependants. 164/  A relatively small
number of co-operative insurance enterprises restrict the
insurance products they provide to their members to enterprise-
related risks, such as transportation, fire, theft, hail and
labour accident insurance and other forms of workmen's
compensation.  A larger number also provide individual-related
insurance products such as home and automobile insurance, as well
as loan protection and pensions.  Although not directly related
to health, each of these contributes significantly to a reduction
in stress and an increase in personal security, both of which
have at least some impact upon individual health. In a number of
cases co-operative insurance enterprises have placed considerable
emphasis on developing insurance products specially designed to
meet the needs of particular section of the population.  This has
been the case in respect to women.  

In Sweden the co-operative insurance enterprise, Folksam, with
which half the population of the country has at least one policy,
has since 1985 developed and marketed insurance products
specifically designed to meet the particular needs of women. 
This was a response to observations that women were less
financially secure, and consequently had a lower standard of
living than men, particularly when they become sick and old. 
Moreover, it became evident that many women were unaware of their
lack of financial security until confronted with it when they
divorced, became ill or old.  They were unaware of their legal
rights, and how to improve their financial security.

Since the 1960s Folksam had been a pioneer in bringing about
equality between women and men employees: in 1978 it adopted the
first full equality programme in the Swedish labour market.   In
1992 it was awarded first prize for furthering equality between
women and men in the workplace by the Swedish Equal Opportunities
Ombudsman and the largest Swedish business magazine, "Veckans
affarer".  Later, when developing insurance products specifically
for women, this internal emphasis was found to be of central
importance in terms both of public perceptions and practical
experience of the requirements of women in respect to insurance,
found to differ significantly from those of men, for whom most
products had been developed.

Folksam had published books by and for women aimed at increasing
their knowledge of finance, law, security and health. In 1985
Folksam decided to make a conscious effort to focus on women as
a specific target group for insurance sales.  This was considered
important not only on ethical grounds, but also in order to
enhance Folksam's image and expand its business prospects.  A
woman was appointed as manager of the "women's market".  A
marketing strategy was developed by seeking to answer the
question "If you want to focus on women's needs, what will you
change in the products you offer, how will you market them, and
what kind of information/education will you need for this?".

An important goal was to raise women's awareness of their
financial situation and degree of security - in particular, women
had to realize their need for improved insurance cover.  In
addition to normal marketing programmes, seminars and lectures
were held at places of work or community centres.  Their purpose
was to identify women's needs for financial security; stimulate
participants knowledge of relevant legislation and negotiated
agreements; motivate participants to use their rights and
opportunities; stimulate them to increase financial security by
using co-operative insurance and banking services; and urge
participants to inform and motivate women colleagues, union
members and daughters. Such meetings were considered essential
also as a means of obtaining first hand and up-to-date
information on women's needs.

Sales teams consisting only of specialist female staff, and
advertising materials developed by and for women, were considered
essential in order to reassure prospective members and policy-
holders.   In 1988 and 1990 Folksam was a major sponsor of the
"Women Can Trade and Idea Fair", and in 1992, although a minor
sponsor, it had one of the largest exhibitions, at which female
employees gave lectures and seminars on women's financial rights
and health problems.

A number of adjustments were made in existing insurance products,
the better to respond to women's needs.  In 1989 Folksam
introduced a collective pension insurance product "Members'
Pension" which, because of its flexible structure and low cost,
was considered particularly suited to women's needs.  By the end
of 1992 86,467 women, compared to 53,298 men had taken out this
insurance.  During this period the premium income from women was
242 million Swedish crowns, compared to that of 148 million from
men.

These efforts paid off in commercial terms. In 1985 Folksam's
market share of newly-issued individual pension insurance
policies was 12.4 for men, 14.1 for women.  By 1991, its sales,
together with those of a wholly owned subsidiary, "Sparliv", had
increased to 28.5 per cent of new policies issued to men, and to
43.2 per cent of those issued to women.165/ 

More directly concerned with health are the insurance products
provided by a substantial proportion of co-operative insurance
enterprises which comprise individual and group life insurance;
personal, school and traffic accident insurance; and disability
insurance.  Although these are more concerned with the
rehabilitation of persons directly affected, and the protection
of dependants, they contribute indirectly to improved health and
directly to the ability of members to provide social care to
themselves or their dependents.

     2.   In respect to health insurance

An increasing number of co-operative insurance enterprises
provide health insurance: there were at 19 in 1995, in 15
countries: Belgium, Canada (3), Colombia, Denmark, Ecuador,
Germany, Italy, Japan, Malaysia, Peru, Republic of Korea (2),
Singapore, Spain, the United Kingdom and the United States (and
separately in Puerto Rico).  They vary in respect to the nature
of their membership base and their organizational relations with
the co-operative structures in association with which they have
developed.  The following types of co-operative insurance
enterprises provide health insurance:

*    specialist insurance department of the national level
     (tertiary) organization established by consumer-owned
     retail co-operatives (Japanese Consumers' Co-operative
     Union: JCCU): this, uniquely, complements health services
     offered by consumer-owned co-operatives also within JCCU;

*    specialist insurance departments of the national level
     (tertiary) organizations established by nation-wide systems
     of primary production co-operatives (the National
     Agricultural Co-operative Federation and the National
     Federation of Fisheries Co-operatives in the Republic of
     Korea);

*    some of the co-operative insurance enterprises established
     at national level by groups of savings and credit co-
     operatives ("credit unions"), or by national federations of
     this type of financial co-operative, providing insurance
     products to their members (several of this type of co-
     operative insurance enterprise exist in Latin America -
     Coopseguros del Ecuador Ltda.; Segurosperu; and Cooperativa
     de Seguros de Vida de Puerto Rico; as well as in Canada -
     the CUMIS Group Ltd.);

*    specialist insurance enterprises established by regional
     co-operative groups: as has been done by the Mondragon Co-
     operative Group, in Spain (Seguros Lagun Aro, S.A. and
     Seguros Lagun Aro Vida, S.A.);

*    some of the co-operative insurance enterprises established
     at national level by groups of co-operatives operating in
     diverse sections of the economy, whether individually or
     through their national federations (the Co-operators Group
     Ltd., in Canada; Seguros la Equidad Organismo Cooperativo
     in Colombia; and the Malaysian Co-operative Insurance
     Society Ltd.);

*    autonomous co-operative insurance enterprises established
     by tertiary level organizations of both rural and urban
     based co-operatives (R+V Versicherung, which developed from
     the Raiffeisen and Volksbank systems, in Germany; 
     Desjardins-Laurentian Life Group Inc., which developed from
     the Mouvement des caisses Desjardins,in Canada; and the Co-
     operative Insurance Society, Ltd., which developed from the
     consumer co-operative movement, in the United Kingdom);

*    co-operative insurance enterprises specializing in
     providing services only to employees of co-operatives
     throughout the country (AP Pension in Denmark);

*    autonomous co-operative insurance enterprises established
     by some combination of co-operative and trade union
     movements (P & V Assurances S.C., in Belgium; Compagnia
     Assicuratrice Unipol S.P.A., in Italy; and NTUC INCOME
     Insurance Co-operative Ltd., in Singapore);

*    autonomous co-operative insurance enterprises established
     by components of trade union movements alone (Amalgamated
     Life Insurance Company, whose members are a number of
     separate "union jointly trusteed funds" established by
     members of clothing workers' trade unions, in the United
     States of America).

The countries within which these enterprises function fall into
several clearly defined groups, a situation which will be
examined below as it suggests certain functional relationships
between societal conditions and this type of co-operative
activity.   The groups are: Latin America (Colombia, Ecuador and
Peru, with which may be associated Puerto Rico); South-east Asia
(Malaysia and Singapore); East Asia (Japan and Republic of
Korea); North America: Canada and the United States (continental
section); and Europe (Belgium, Denmark, Germany, Italy, Spain and
United Kingdom).

There are in addition to these purely co-operative insurance
enterprises, a number of "mutuals" whose organizational structure
is similar to that of co-operatives, and whose members are drawn
from a professional or other occupational group, provide health
insurance among a range of individual-related products.  Examples
are the Wiener Stadtische Allgemeine Versicherung
Aktiengesellschaft in Austria;  the Sociedad de Seguros de Vida
del Magisterio Nacional in Costa Rica; the Tapiola Insurance
Group in Finland; and Nationwide Insurance Enterprise in the
United States of America (whose members were originally farmers
and which has strong links with agricultural co-operatives).  

Health insurance was also offered by three enterprises defined
as mutuals but having significant associations with the co-
operative movement in respect to origins or current ownership and
alliances: these were located in the Netherlands. Two mutual
organizations also provided health insurance. They were located
in Austria and Indonesia. In France the system of mutual
organizations (la Mutualite) had an integral partnership function
with the national social security and health insurance system
(see Chapter II, section J).166/ In Europe an estimated
100,000,000 persons have health insurance provided by such mutual
enterprises.  

The quantitative dimension of health insurance provision by co-
operative enterprises is not known in full.  For those
enterprises for which information is available, NTUC INCOME in
Singapore had 18.9 per cent of the health insurance market, but
percentages were much smaller elsewhere: Compagnia Assicuratrice
UNIPOL in Italy (2.9); the Co-operators Group Ltd. in Canada (2.0
- 3.0); Seguros la Equidad Organismo Cooperativo in Colombia
(1.8); P&V Assurances S.C. in Belgium (1.0); Segurosperu (0.2);
and R+V Versicherung in Germany (0.1).  

While NTUC INCOME had the highest market share, this involved
only 723 policies (it is not known if these are group or
individual).  Unipol (Unisalute) had a market share of only 2.9
per cent, but this was made up of 24,998 policies in 1994.  The
very early phase of development in health insurance provision is
shown by the fact that the Belgian co-operative insurance
provider P&V managed 4,000 health insurance policies (1 per cent
of the market) compared to 460,000 individual life policies (4.5
per cent of the market).

These relatively low proportions reflect in part the recent date
of entry into the market of most of these enterprises, as well
as the existence of national health and social security coverage
which they are able only to complement but not replace.  

One of the 19 co-operative insurance enterprises which at present
offer health insurance was established in 1867, and three others
in the early decades of this century (1907, 1919 and 1922), but
four others were founded between 1943 and 1954, the greater
proportion between 1959 and 1970 (seven enterprises) and three
subsequently (1983, 1989 and 1994).  Their health insurance
products were introduced much more recently in each of the cases
for which information is available: four enterprises did so after
1988 (1988, 1989 and 1995), and three others did so at unknown
dates during the 1980s.

In some countries co-operative insurance enterprises are closely
integrated with broad sectoral co-operative organizations.  For
example, in Japan, early in 1996 there were 2,836 multifunctional
agricultural co-operatives: they provided credit, purchasing,
extension and marketing services to the 8,840,000 agricultural
producers who were their members.  They also provided welfare,
health and insurance services for members and their dependants
(the total population in farm households was 17,290,000 in 1990,
of which 5,650,000 were employed in agriculture).

Agricultural co-operatives, which exist largely at the level of
municipalities, have organized federations at the prefectural
(regional or sub-regional) level in respect of each of the
distinct types of function undertaken by agricultural co-
operatives.  The specialist prefectural federations in turn have
organized national federations, again, by distinct types of
function.

Hence, there are prefectural federations responsible for
providing insurance to members of all of the agricultural co-
operatives operating within the prefecture.  These are known as
Kyosairen.   They have established a national federation
responsible for insurance, known as Zenkyoren (the National
Mutual Insurance Federation of Agricultural Co-operatives). 
Zenkyoren is engaged in the development of new insurance
products, risk pooling and fund management, and providing
guidance to prefectural federations.

There exists also a parallel system of prefectural level "welfare
federations", responsible for all the health and welfare services
provided to all members of agricultural co-operatives operating
within the prefecture.  They are known as Koseiren.  They have
also established a national federation, the National Welfare
Federation of Agricultural Co-operatives, known as Zenkoren.167/ 

The fact that some of these enterprises have not yet moved into
the health insurance market reflects the still substantial
provision by national health insurance: for example, in Denmark
the co-operative insurance enterprises which provides insurance
to employees of co-operatives (AP Pension) does include health
insurance already in its products, but the analogous enterprise
in Sweden (KP Pension & Forsakring) does not.  Among seven co-
operative general insurance enterprises set up jointly by the co-
operative and trade union movements in European Welfare States,
two provide health insurance (P & V Assurances S.C. in Belgium
and Compagnia Assicuratrice Unipol S.P.A. in Italy), but the
others do not (Forsikrings-Aktieselskabet ALKA in Denmark,
Vatryggingafelag Islands in Iceland, the Samvirke Group in
Norway, the Folksam Group in Sweden and COOP Versicherung in
Switzerland).

There is clearly a very considerable potential for expansion of
the involvement of certain types of co-operative insurance
enterprises in the provision of health insurance.  Entry into
this market, or expansion of life-insurance types of product to
health insurance, cannot be expected from those enterprises
specializing in enterprise-related products.   However, where
large national co-operative movements, involving high proportions
of individuals within certain occupational groups, such as
agriculture, already have specialist insurance departments or
subsidiary enterprises, it would seem that engagement in health
insurance would be both feasible and appropriate.   An example
might be the National Mutual Insurance Federation of Fishery Co-
operatives (Kyosuiren) in Japan.

Particularly where co-operative insurance enterprises have been
set up specifically to provide individual-related life insurance
products, the addition of health insurance would be a logical
next step.  Examples might include the Co-operative Insurance
System of the Philippines; the co-operative insurance enterprises
established by savings and credit co-operative ("credit unions")
in countries with poorly developed national health insurance
systems, such as those in Barbados, Bolivia and Guatemala; those
enterprises set up by diverse groups of co-operatives, again in
countries with poorly developed national health insurance
systems, such as the Mayor Seguros Cooperativa de Seguros in
Argentina, Asseguradora Solidaria de Colombia, Cooperativa
Nacional de Seguros in Dominican Republic, Syneteristiki
Insurance Company in Greece, Koperasi Asuransi Indonesia, Co-
operative Insurance Services Ltd. in Kenya, World-Wide Insurance
Company in Nigeria and Uganda Co-operative Insurance Ltd.

With further retrenchment in national social security and health
insurance systems in countries with welfare state structures, the
co-operative insurance enterprises which are very well developed
in many of them, could be expected to expand their health
insurance products, particularly if adjusted to certain sections
of the population most at risk, such as women, self-employed
persons, long-term unemployed persons and the elderly.  In this
way they could complement the basic provision by the public
sector which can be expected to remain.

An example of the contribution that co-operatively organized
insurance enterprises are capable of making to health and social
care in contemporary societal conditions is provided by Unipol
Assicurazioni in Italy, which announced early in 1995 that it was
to set-up a new health insurance company, Unisalute.  Unipol was
building a network of agreements with preferred managed health
care providers and discussing the venture with other entities
within the social economy.  Its primary targets were employed
workers interested in supplementing the public health and social
security system by taking out group health policies through
collective bargaining at the enterprise level through the
mediation of trade unions.  Unipol believed that only by
organizing aggregate demand in this way could insured worker's
interests be safeguarded from exploitation by health service
providers.168/

In Italy, the national health system has covered almost all
medical requirements for all citizens since 1978 when a major
reform was undertaken.   Nevertheless, the service now provided
is reported to be in many ways not satisfactory.  In the public
health sector expenses have increased rapidly, exceeding receipts
by the equivalent of over 10 billion US dollars in 1994.  As a
result, services are running down in many regions and there is
lack of investment in research.  Consequently, many persons find
it necessary to use private services in order, for example, to
avoid the long waiting lists normal for users of public
facilities.  They have to pay themselves for doing so: in 1993
it was estimated that such payments totalled the equivalent of
about US $ 20 billion.  Moreover, few were able to recoup these
expenditures through private health insurance. Because of the
nominal comprehensive coverage of the public system, the private
health insurance sector remains largely underdeveloped, and
restricts its market targets to upper income sections of the
population.  Consequently, only highly expensive products are
available.

In response to this situation a further reform in the health
system began in 1993.  Among other things it offered new
opportunities for the development of private initiatives.  Health
care funds were introduced to offer citizens services
supplementary to those of the public system. These funds can be
set up either through agreements between employers and employees,
or through voluntary agreements among employees. They can be
self-managing, or run by insurance enterprises, or by mutuals
dealing exclusively with health matters.  The latter option was
scarcely developed: in 1995 there were only a few small mutuals
in the country.

In this new situation the Unipol co-operative insurance group
created an enterprise called Unisalute, which was to become fully
operational late in 1995. Its function was to provide quality
health insurance policies at fair prices, primarily to persons
associated with certain types of partner organizations, as well
as their dependants. These would include about 2,500,000 members
of consumer co-operatives; 6,000,000 members of employee trade
unions, who held group insurance policies resulting from
bargaining between their unions and employers; a little less than
1,000,000 members of self-employed persons' trade unions
(principally farmers, shopkeepers and craftsmen); account holders
in cooperative or other social economy banks, such as the Savings
Bank of Bologna, which together operated 450 branches throughout
Italy (through the "bank assurance" system); and policy holders
in mutual insurance enterprises, such as Reale Mutua, which are
partners of Unipol.  This potential market amounted to about
10,000,000 persons.

As a complement to its sale of health insurance, Unisalute would
set up a network of contracted providers of health care services,
including doctors' practices, clinics, specialist centres and
nursing homes.  One would be responsible for health care
management: it would undertake agreements with providers, control
the quality and cost of services and suggest the best solutions
for complicated cases.  Unisalute would recommend to its policy
holders preferential use of the network of contracted providers. 
If this were done it would pay for the services provided without
cost to policy holders. In addition to reimbursing its policy
holders, or making direct payments to contracted providers,
Unisalute would help them identify the most appropriate provider
and would undertake appropriate negotiations with them on behalf
of policy-holders. A second component of the service provided by
Unisalute to its policy-holders will comprise a customer service
department offering assistance to both clients and to service
providers.  A 24-hour help line would guarantee emergency medical
attention and advice.  Finally Unisalute was to undertake health
information and prevention campaigns - an area neglected by the
national health system. 

Such an engagement in the health and social care sector would
constitute a re-establishment of the role of co-operative
insurance in the countries now welfare states.  The experience
of the United Kingdom prior to the establishment of the welfare
state in 1948 is testimony of their potential.  Here health
insurance was provided predominantly by "friendly societies". 
These could be traced back to the seventeenth century.   Some
developed under the patronage of the upper classes, but,
particularly during the course of the industrial revolution, the
majority were established by workers to meet their needs.   They
were self-governing and democratically organized associations not
greatly different from co-operatives.  It has been estimated that
at least one quarter of male workers (representing a similar
proportion of the total population) were members of such
societies by 1830. 

From the 1830s the community-based and self-governing working
class societies came to be complemented by larger organizations,
with affiliated branches, two of which developed to national
dimensions.  They were able to offer safer investments and more
generous benefits.  Members were drawn from workers in the more
regular types of employment, able to plan for regular
commitments.  By the 1870s there were about two million members,
about 30 per cent of adult males.  The poorer workers could
afford only to join "burial clubs" which provided them only a
minimal death benefit.  However, during the mid-nineteenth
century there developed from these societies large commercial
enterprises, known as "industrial assurance" societies, in which
there was no control by policy-holders.

Toward the end of the nineteenth pressure grew for the state to
provide comprehensive sickness benefits and old age pensions.  
When the former was introduced in 1911 friendly societies, both
those which were community-based and member-controlled and those
which were investor-owned and profit-oriented commercial
enterprises, continued to have a role: they were made responsible
for collecting contributions from employees, which were then
topped up with state funding.  This benefitted the commercial
enterprises more than the smaller member-owned friendly
societies, but these did at least continue to function.   When
in 1948 the Government introduced the comprehensive safety net
of national insurance, they dispensed with the services of the
friendly societies and set up a totally state funded and
administered system of social security and health benefits and
services.169/

     3.   In respect to preventive health

Co-operative insurance enterprises emphasize prevention as the
best way to reduce costs of insurance to their members.  To be
successful in prevention, they consider it necessary to achieve
the fully informed participation of all members, and to support
member participation in the broadest possible community and
societal activities which will result, directly or indirectly,
in reduction of risk.  They devote considerable resources to
prevention of domestic accidents, particularly those involving
children, and to sport, leisure and traffic accidents affecting
in particular young persons.

Most co-operative insurance enterprises are engaged in preventive
health, including research into the courses of risk and loss. 
This is the case, for example, in Japan, where the co-operative
insurance organizations at regional and national levels
(Kyosairen/Zenkyoren) have attempted to reduce risks by promoting
traffic safety and by health management.  In the immediate post-
war period these co-operative insurance institutions undertook
mobile health counselling programmes, financial assistance for
health examinations and for improving rural housing and village
environments.  They also supported the establishment of welfare
federations, Koseiren.  More recently, Kyosairen/Zenkyoren have
emphasized a preventive approach to health by the elderly. 
Recreation, sports, health examinations are promoted.  A
telephone health counselling service has been set up.170/ 

Since the mid-sixties Folksam, the Swedish co-operative insurance
society, has made an internationally recognized contribution to
auto safety for the benefit of all auto users and insurers.  This
has included traffic safety research and research on personal
accidents and design of cars, published in regular reports on the
interior safety level of cars.  Other research has been
undertaken in collaboration with universities and other
interested parties: experimentation with the promotion of
orthopaedic rehabilitation; evaluation of ambulance systems to
enhance the training and education of personnel, as well as the
ambulances; neck and shoulder pains, both world-related and as
a result of road accidents; asthma and allergy problems; heart
attacks and vascular disorders; experimentation with models of
rehabilitation services to be offered to members of trade unions
insured by Folksam.  

These activities are initiated and administered by Folksam's
Scientific Council. They have often resulted in practical
measures being undertaken to promote health and prevent accidents
and losses. In collaboration with other social economy
organisations, Folksam has established a Social Council to
promote information on loss prevention health and related issues
including homelessness; alcohol and drug abuse, the situations
of the handicapped; immigrants in the welfare state; the
situation of children and young people; problems of working life;
early retirement; equality and men's and women's roles;
consequences of the changes of the welfare state; pollution and
environmental conservation; cancer; good working conditions;
injuries in sports activities and their prevention; mental
health; suicide; the use of seat belts, etc.  

Books and other publications offer member policy-holders and
others a wide variety of information concerning health and
rehabilitation matters, social welfare policy, economy and legal
matters, school issues, traffic safety, etc.  

These activities have been undertaken as an expression of the
wider perspective concerning the basic aim of an insurance
enterprise, natural for a co-operative.  A co-operative insurer
is entrusted by its policyholders, who are its members and
owners, to look after their interests in a comprehensive sense,
e.g. to prevent losses, to limit their effects, and to
rehabilitate injured policyholders.  To do this efficiently, it
is necessary to engage in research directly or to promote it in
various ways.  A similar perspective is needed by all kinds of
co-operative in the health and social care sectors. 171/  

     4.  In respect to social care

A number of co-operative insurance enterprises are engaged
directly in the provision of social care services, as an
extension of their broad concern with preventive and
comprehensive approaches to meeting the needs of their members. 
This has been the case, for example, in Japan with the insurance
enterprise owned by the national system of agricultural co-
operatives.  


Revision of the Agricultural Co-operative Association Law in 1992
made it possible for the movement to undertake programmes related
to the welfare of the elderly. The prefectural federations
responsible for providing insurance services to agricultural co-
operatives, Kyosairen, together with the national apex
organization, Zenkyoren, established in 1992 a group responsible
for examining the health and welfare of elderly persons.  This
step was taken in response to the findings of research undertaken
by the Agricultural Co-operative Insurance Research Institute
(Nokyo Kyosai Sogo Kenkyujo), the research organ of the
Kyosairen, concerning projections of elderly persons requiring
nursing care in rural areas.  These showed that in rural areas,
not only was the rate of increase of the elderly population much
higher than the national average (already among the highest in
the world), but elderly persons faced severe difficulties in
obtaining care, owing to the out-migration of younger persons and
the problems of access in rural areas.

A national level Council to Promote the Welfare of the Elderly
was set up.  Education and training materials and support for the
establishment of local mutual help groups have been developed. 
By 1995 10,100 persons had been trained as home helpers,
providing assistance in household work, and 957 persons trained
to provide nursing care.   75 mutual-aid groups within individual
agricultural co-operatives were established in 1993.   The
programme in progress during 1995 was designed to train 38,200
home helpers and 26,200 home nursing care givers, as well as to
set up 1,000 mutual aid groups.  It is planned to extend services
to the operation of special nursing homes for the elderly.

In order to expand home nursing care for the elderly and for
persons with disabilities in rural areas, Kyosairen/Zenkyoren
provide subsidies and scholarships to promote increase in numbers
of trained personnel and assist in the establishment of
rehabilitation facilities. Special occupational insurance, both
against accident and liability, has been introduced to cover
volunteers engaged in providing home care services to the
elderly, and drawn from women's and youth sections of
agricultural co-operatives.  Since 1973 they have operated two
rehabilitation centres, one for persons with disabilities, one
for persons recovering from traffic accidents.172/

In Belgium, the co-operative insurance group P&V, which was
founded in 1907 as a result of initiatives taken by the Belgian
Worker's Party in order to overcome the problem faced by lower-
income families frequently the victims of unscrupulous and
unregulated private for-profit insurance enterprises, expanded
rapidly n the basis of the value of mutual assistance. From 1934
onwards it devoted a considerable proportion of its surplus to
social welfare and humanitarian programmes.  At present it
continues to provide social security and services to independent
workers.173/

     F.   SAVINGS AND CREDIT CO-OPERATIVES AND CO-OPERATIVE
          BANKS [TYPE 2.3.4]

In China prior to the Second World War a number of rural credit
co-operatives undertook to raise the health standards as well as
the economic conditions of their members.  They attempted to
improve sanitary conditions, install baths, arrange vaccinations
and provide medical and surgical attention.174/ 

In the United States the National Association of Retired Credit
Union People (NARCUP) supports fuller use by elderly persons of
savings and credit co-operatives, including their remaining
members after retirement - an important factor given that in the
United States a high proportion of credit and savings co-
operatives operate as organizations formed by the work-force of
large public or private enterprises. The Association's programmes
promote adjustment by credit and savings co-operatives of their
business goals and practices in order to provide services
tailored to the special needs of older persons. In Canada the Co-
operative Superannuation Society has since 1943 administered the
pension funds of employees of co-operatives. 176/ 

G.   Housing and community development co-operatives [type
          2.3.5]

In Canada the Executive Director of the Co-operative Housing
Federation, in a 1994 statement of the principles and aims of
Canadian housing co-operatives, explained that the Federation was
committed to include people with special needs, preferably in
environments that fostered integration.  The design of buildings
should encourage occupancy, full participation and social
integration of people with physical disabilities. Each co-
operative should try to accommodate one or more other groups with
special needs.  Housing co-operatives would meet their
responsibilities to the larger community by upholding principles
of social justice within their communities, and by promoting
public concern over domestic violence, among other things.   They
should support the health and well-being of employees. 177/

A number of housing co-operatives have declared themselves to be
"domestic violence free zones": membership of abusers can be
terminated on petition from other members; subsidies can be
provided to victims so that they may remain in their homes while
seeking financial assistance and support payments; information
is provided on where to seek counselling and other forms of
assistance; and close working relationships with the police are
developed.178/  

In Sweden housing co-operatives which are members of the national
apex organization, HSB: Riksforbund have expanded traditional
functions in property management and caretaking into house-
keeping services and thence to home care and home nursing.  They
have also sponsored day-care services. In many areas these have
become autonomous co-operatives, the members of which are
simultaneously members of the housing co-operative.  For example,
in Snopptorp, a housing co-operative in Eskilstuna, home help and
home nursing have been undertaken by a co-operative since early
1991.  In some cases these co-operatives have moved further from
their original association with housing co-operatives, opening
their membership to all within the community. In several
locations, co-operatives members of the HSB and Riksbyggen
movements own and operate blocks of service flats and other
dwellings for the use of elderly persons and persons with
disabilities.179/

Home-care services for elderly persons have been promoted by the
housing co-operative movement, largely on behalf of elderly
members, but partly as a form of community service.  After the
discontinuation in 1992 of the "Medikoop" initiative undertaken
jointly with Folksam, 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.   Purchasers of the services were
municipal authorities, responsible for provision of care for
elderly persons.  Local associations of users were also involved
in the organization. 180/ 

In the United Kingdom, the recently implemented policy of
transferring responsibility for providing care in their own homes
to many elderly and disabled persons has implied a substantially
increased responsibility for housing co-operatives.181/ 

In the United States a number of housing co-operatives for older
persons have been organized on the basis of a model developed by
the Ebenezer Society, based in Minneapolis, Minnesota. The
largest is Cooperative Services Inc. in Detroit, Michigan. This
operates 31 housing co-operatives for elderly people in four
states that have 5,000 persons.182/

In New York City an innovative programme for the provision of
comprehensive health and social services to elderly persons in
a co-operative housing context began in 1986.   The NORC
(Naturally Occurring Retirement Community) Project at Penn South
Co-op (Mutual Redevelopment Houses, Inc) was set up in 1986 to
provide organized, comprehensive services for the elderly persons
living in a 2,800-unit housing cooperative complex. Its purpose
was to make supportive services available to older people in
their lifelong residences and enable them to secure health care
and an independent, dignified lifestyle within "Naturally
Occurring Retirement Communities".  These are defined as housing
developments in which at least half of residents are persons aged
60 or over, but which were not designed originally to meet the
needs of older residents.

Since its establishment the NORC Project at Penn South Co-op has
become a model which has been replicated widely in New York City. 
10 other similar programmes, mostly located in housing co-
operatives, have been set up subsequently.  These are funded in
part by the State of New York.  A national network of NORC
projects has been established with the help of a loan from the
Cooperative Development Foundation.   

The Penn South NORC Project has annual operating costs of US $
400,000 and is supported through the general operating funds of
the Penn South housing cooperative, as well as through
philanthropic, corporate and in-kind donations.  The project
secures cost-efficient social and health services for elderly
persons by pooling health provider case loads and by assisting
the most appropriate health and social service intervention
techniques for each resident within a coordinated system for each
housing co-operative.  It avoids costly hospitalization or
institutionalization by making regular home check-ups,
supervising medication intake and monitoring environmental health
conditions within the elderly persons' own apartment.  This is
done by means of a network of health and social service
professionals and volunteers.  Recreational and educational
activities are provided for residents, stimulating a sense of
community and inclusion, and thereby taking away the stigma of
"needing help". 

A 1993 study of the NORC Project at Penn South by the Brookdale
Center on Aging at Hunter College, a component of the City
University of New York, concluded that elderly persons benefitted
from its approach in the following ways: (a) improved mental and
emotional health arising from residence in an integrated
community of mutual aid; (b) significant decline in health care
costs; (c) enhanced economic and physical security through
advocacy for elderly persons with apartment management,
government agencies and legal authorities; and (d) avoidance of
social and economic dislocation caused by institutionalized
care.183/

     H.   ENVIRONMENT MANAGEMENT, SANITATION AND CLEANING CO-
          OPERATIVES [TYPE 2.3.6]

Innovations in cleaning procedures, and use of more appropriate
cleaning materials, in work-places, hotels, places of recreation
and public assembly have been introduced by co-operative
enterprises, with improvement in the health impact of the built
environment.  For example, the Finnish co-operative EKA Group has
introduced within the hotels operated by its Restel subsidiary
improved forms of room cleaning.  There is considerable scope for
contributions by worker-owned and labour-contracting co-
operatives in this area: in many countries they are beginning to
have a significant market share of "environmental services":  for
example the Premier Environmental Services Co-operative Society
Ltd., in Singapore.  The labour-contracting co-operative formed
by poor women cleaners, members of the Self Employed Women's
Association in Ahmedebad, India, have improved the condition of
the poorest group of women cleaners and refuse collectors. In
India during the 1920s to 1940s there were over 1,000 "Anti-
malaria" co-operatives which filled cesspools, cleared vegetation
and drained ponds.184/

     I.   CO-OPERATIVES WHOSE BUSINESS GOALS MIGHT INCLUDE
          PROVISION OF OPERATIONAL SUPPORT TO HEALTH AND SOCIAL
          CARE CO-OPERATIVES [TYPE 3]

     1.  Financial co-operatives [type 3.1]

     (a)  Cooperative banks

Health co-operatives in India, Sri Lanka and the United States
are known to have received loans on favourable terms from co-
operative banks.  In the United States the National Co-operative
Bank's Development Corporation has provided funding to user-owned
health co-operatives, as well as to the semi-co-operative
Government sponsored community health centre system.  The only
case of a health co-operative system developing its own financial
capability, is Unimed in Brazil, with its Unicred and Unimed
Aseguradora subsidiaries. 

     (b)  Savings and credit cooperatives ("credit unions")

In Quebec, Canada, the Mouvement des caisses Desjardins has
supported a number of health and social care co-operatives during
their take off phases.  

     (c)  Insurance cooperatives

In Quebec, Canada, a number of mutual insurance enterprises have
supported the take off phases of health and social care-co-
operatives. These enterprises are particularly interested in
health insurance, in the context of the current crisis in public
finance, and the rationalization of public spending in health and
related fields.  Currently they provide a complementary health
insurance programme to the population of the Province.

The close involvement of these enterprises in the development of
health co-operatives is illustrated by the history of one of
them, "SSQ", which itself began operations as a health co-
operative in 1945, prior to the establishment of the welfare
state system. It provided affordable and high quality health
services to low income residents in one of the poorest
neighbourhoods of Quebec City, Sainte Saveur.  It was initiated
by a doctor, Jacques Tremblay.  Achieving considerable success,
it expanded its services to the whole City, and thereafter widely
throughout the Province of Quebec.   When a national health
service was established in 1960 "SSQ" concentrated its activities
in the group insurance field.185/ 

     2.   Co-operative research and development institutions
          [type 3.2]

     (a)  At the national level

At the International Co-operative Health and Social Care Forum,
held at Manchester, United Kingdom on 18 September 1995 in the
context of the Centennial Congress of the International Co-
operative Alliance, several participants reported ongoing
research.  From this and other sources it is known that research
on health co-operatives is in progress in Argentina, Canada,
Costa Rica, Italy, Japan, Spain, Sweden, the United States and
the United Kingdom.  

In Argentina research is being undertaken at the Gabinete de
Estudio y Promocion del Cooperativismo Sanitario at Buenos Aires.
186/ 

At the Department of Co-operatives ("chaire de cooperation Guy-
Bernier") in the University of Quebec at Montreal, Canada,
exploratory research on the development of health co-operatives
in eleven countries (Brazil, Canada, Costa Rica, India, Japan,
Malaysia, Panama, Spain, Sri Lanka, Sweden and the United States)
has been undertaken by Professor Yvan Comeau of Laval University
and Professor Jean-Pierre Girard of Sherbrooke University.  The
purpose has been to stimulate discussion concerning the
reorganization of the health delivery system in Canada.  The 11
country study,"les cooperatives de sante dans le monde: une
pratique preventive et educative de la sante" was published by
the University in April 1996.  As part of this research the
Department undertook a field study in 1995 of the development of
health co-operatives in Costa Rica.  This was undertaken with the
collaboration of Jorge Barrantes, a Costa Rican student at the
University of Quebec at Montreal.187/  Previously, the Canadian
Co-operative Association sponsored research on co-operative
community health clinics.188/

In Italy in 1993 the Centro Studi in the Consorzio Nazionale
della Cooperazione di Solidarieta Sociale "Gino Matarelli"
undertook a survey of 660 of the estimated 2,000 "social co-
operatives".189/   

In Japan research is in progress in the School of Social Sciences
of Ritsumeikan University: a graduate student, Keiko Kawaguchi,
reported to the Forum on alternative management strategies for
health co-operatives.190/  The Japanese National Welfare
Federation of Agricultural Co-operatives, the apex organization
of the user-owned health co-operative movement associated with
the system of multi-functional agricultural co-operatives, set
up in 1952 an Association of Rural Medicine which has made
significant contributions to the study of the impact of
substances used in agricultural production on the health of rural
populations.191/

The work of the Espriu Foundation in Spain is devoted entirely
to this area of co-operative enterprise.192/  Professor Isabel
Vidal of the "Centre d'Iniciatives de l'Economie Social" in the
University of Barcelona, is responsible for research on social
co-operatives in Europe.  The provider-owned health co-operative
CES Clinicas in Madrid works closely with the School of Co-
operative Studies of the University Complutense of Madrid 193/ 

In Sweden, with adoption in 1991 of policies to decentralize
responsibilities from central to local government authorities and
to promote privatization to some extent, national level co-
operative organizations (the Cooperative Institute, the Union of
Housing Co-operatives (HSB: Riksforbund) and the co-operative
Folksam Insurance Group, developed the "Medikoop" model for
consumer-owned co-operative health centres, designed not to
replace but to complement the public system.194/

In the United States, at the University of North Carolina, a
rural health research programme has included an examination of
health co-operatives.195/

In Sweden the Co-operative Research Institute (KOOPI), the Agency
for Co-operative Development at Goteborg (Kooperativ Konsult) and
the Department of Business Administration at Stockholm University
are each carrying out research on co-operative and other "third
sector" developments in both health and social care within the
context of changing relationships between the state, the market
and civil society.196/  At the latter institution research
projects include one on provider-owned social care co-operatives
within the context of the changing circumstances of the welfare
state in Sweden.197/

Co-operative insurance enterprises do not have to rely upon data
from other sources: the data they possess on loss (claims against
policies for life, disability, accident, unemployment, pension,
property etcetera) are among the most sensitive and current types
of information, available to them for immediate analysis,
providing that they maintain appropriate data management and
analytic resources.  Analysis of this data constitutes a unique
opportunity to quickly monitor negative trends, give advance
warning of potential problems and initiate research to produce
corrective measures and wherever possible longer-term preventive
measures.  

The major co-operative insurer, Folksam, has a Social Council,
which acts as a "think tank" in respect to risk, loss prevention
and rehabilitation, and social, medical and economic questions. 
Its functions include undertaking research, organizing seminars,
publishing studies and information material, organizing lobbying
campaigns, shaping public opinion, participating in national
policy development and maintaining relations with partners.   The
Council was set up in 1971 by combining Councils for Social
Information, Women and Youth, set up during the 1960s. It is
composed of representatives of Folksam itself, other co-operative
movements, trade unions and other people's organizations.  During
1996 the Council was to look more deeply into the implications
of "downsizing" social welfare and of increased unemployment in
Sweden. In 1992 it had begun a research project on early
retirement in collaboration with the Department of Labour and
Organizational Psychology of the university of Stockholm.  In
1995 a two year research project began on gender aspects of
working activities within the Folksam Group itself.198/ 

In the United Kingdom, the Government's Department of Health has
funded a study undertaken by the Centre for Research in Social
Policy at the Department of Social Sciences, Loughborough
University.  An early draft has been approved already by the
Department, and the final report submitted to it in late 1995. 
The study, on "The potential contribution of the co-operative
movement and community well-being centres to "Health of the
Nation" activities", comprised a literature review, identifying
the scale, scope and defining characteristics of health-related
co-operative and community schemes and centres; a review of the
evaluation processes used in these schemes and centres; and an
assessment of the potential contribution to the national "Health
of the Nation" policy of the United Kingdom Co-operative Council,
Community Well-being Centres and other co-operative groups.199/ 

The Co-ops Research Unit at the Open University at Milton Keynes 
examines opportunities for co-operative developments in the
health and social care sector as broad changes in the welfare
state and in society occur.200/   The Industrial Common Ownership
Movement Limited (ICOM), which represents worker-owned co-
operatives of all kinds, is concerned with the development of
provider-owned co-operatives in these sectors.201/

Research is carried out not only by specialized co-operative
research and development institutions but by many of the larger
user- and provider-owned health co-operatives, such as the Group
Health Co-operative of Puget Sound, and Unimed in Brazil.  They
examine not only organizational and operational matters, but also
programme development and delivery, preventive health as well as
environmental factors relevant to health and social well-being. 
In some cases they undertake policy-oriented research in support
of lobbying. Co-operative insurance enterprises undertake similar
research.  

     (b)  At the regional level

Research is also being undertaken at the regional level in
Europe.  In collaboration with the Italian Consorzio Nazionale
della Cooperazione di Solidarieta Sociale "Gino Mattarelli", the
research network, Euroforcoop, of the European Committee of
Workers' Co-operatives (Comite Europeen des Cooperatives de
Production et de Travail Associe: CECOP) undertook during the
period from September 1995 to December 1996 the first part of a
review of national experience in respect to the organization and
operation of social cooperatives. This covered the situation in
nine countries of the European Union (Belgium, Denmark, France,
Germany, Italy, Portugal, Spain, Sweden and the United Kingdom). 
It revealed that changes in the social care sector required new
forms of organization capable of synthesizing the advantages of
private enterprise with recognition of the interests of the
community.  Findings were presented at a conference held at
Brussels in 1995.  A second phase of the review would be to
enlarge the research network to remaining member countries of the
European Union, extend the scope of the study to a more detailed
examination of social cooperatives as new forms of organization
in the sector, and diffuse results by a means of a series of
seminars and an electronic bulletin board. 202/ 

In February 1996 CECOP organized at Barcelona, Spain, in
collaboration with the Federation des Cooperatives de Travail
Associe de Catalogne (FCTAC), and with the support of the
European Union and the Department of Employment of the
Generalitat de Catalunya, a conference in the series "Journees
europeenes de la cooperation sociale" on "social welfare in
Europe and new opportunities for the creation of employment in
the area of social services". 203/  The "Centre d'Iniciatives de
l'Economie Social" of the University of Barcelona, under the
direction of Professor Isabel Vidal, also recently organized a
conference on this topic, on the basis of which a publication was
issued.204/ 

ICA's Regional Office for the Americas, whose headquarters are
in Costa Rica, recently initiated a review of the actual and
potential development of health co-operatives in central America. 
The results are not yet available.205/

     (c)  At the global level

The ICA Committee on Co-operative Research, which originated in
a "research officers' group" in the early 1950s, organizes a
global network of researchers by means of which knowledge is
improved and new models disseminated.  The Committee holds an
annual seminar.  In recent years it has devoted increasing
attention to the establishment and operation of co-operatives in
the health and social care sectors.   Publication of its
proceedings has been hampered by financial constraints.206/

     3.   Co-operative media enterprises and activities [type
          3.3]

The co-operative principles included within the "Statement on the
co-operative identity" adopted by the ICA's Centennial Congress,
held at Manchester, United Kingdom in September 1995 - and
intended to function as guidelines by which co-operatives
throughout the world put their values into practice - include as
the fifth principle "education, training and information".   This
principle states that co-operatives  provide education and
training for their members, elected representatives, managers,
and employees so they can contribute effectively to the
development of their co-operatives.  They inform the general
public - particularly young people and opinion leaders - about
the nature and benefits of co-operation.  For this reason
individual co-operative enterprises and business groups, co-
operative organizations at secondary and tertiary levels, and
organizations of the international co-operative movement, have
all paid particular attention to the dissemination of information
concerning co-operatives, including potential and opportunity for
co-operative forms of organization in new sectors.  They also
disseminate widely information on health and social care.  This
has been done by means of all forms of information diffusion,
from simple newsletters to the Internet.   Some co-operative
organizations operate, as a subsidiary or affiliated enterprise,
a newspaper or radio or television station.  In Singapore, for
example, the national trade union movement has supported the
establishment of a radio station organized as a cooperative whose
owners and members are individual trade unions.207/

In addition, within the media sector, a considerable number of
enterprises of all types are organized as co-operatives.  They
include worker-owned co-operatives whose members are journalists
(such as Inter-Press) or broadcasters, as well as entire
newspapers, radio and television broadcasting stations.  In some
cases co-operative organizations combine to set up media
enterprises - for example in the United States the National Rural
Telecommunications Cooperative, established in 1986 and owned by
almost 800 rural electricity and telephone cooperatives,
broadcasts a package of television programmes to over 90,000
rural households.208/ 

Information on healthy living, appropriate nutrition, reduction
in environmental hazards and preventive health is already widely
diffused through the co-operative media. For example, in 1993 the
Union Nacional de Cooperativas de Consumidores y Usuarios in
Spain issued a "Guide to Ecological Living".209/  Closer
attention to the potential for closer and more direct engagement
by co-operative enterprises of many types, but including health
and social care co-operatives and co-operative insurance
enterprises is already evident, and is likely to expand rapidly
in the near future.

The Swedish co-operative insurer, the Folksam Group, set up in
1971, a "Social Council", one of whose functions was to publish
and distribute material on current societal trends and their
implications for members and the communities in which they live
and work, as well as background information needed to inform
public opinion and ensure an effective participation in national
policy debate and formulation.   Material is published at low
cost and distributed both to individuals and organizations. 210/ 

Some of the co-operative research organizations contribute to the
publication of material on co-operative forms of provision of
health and social welfare services.  For example, the Studies
Centre (Centro Studi) of the Italian Consorzio Nazionale della
Cooperazione di Solidariet… Sociale "Gino Matarelli" publishes
its own "CGM" Editions.211/

While the co-operative media is a valuable supplementary source
of information for many co-operators and co-operative employees
who are within the middle-income and more secure lower-income
strata, it is often the only source of information for many
members of co-operatives, and for entire communities in which
these co-operatives exist. The potential of co-operative media
can be appreciated when it is recalled that individual members
of co-operatives total about 800,000,000 persons throughout the
world, which implies, if only their immediate family is included
(and estimated at an additional three persons), a consumer
population of about 3,200,000,000 - over half the world's
population.

Moreover, members of co-operative enterprises, because their
values and principles include concern for the community in which
they work and live, are particularly receptive to ideas and
information on best practices within the co-operative movement,
and in affiliated organizations. Information diffused through the
co-operative media is likely to meet with closer scrutiny than
that diffused through more general channels.  In this regard it
is important to keep in mind that for most individuals, their own
health and well-being, and that of their dependants, is a matter
of central importance: and one not adequately addressed either
by governmental public information channels, or by the for-profit
media.

     4.   Training and education co-operatives [type 3.4]

One of the co-operative principles adopted in September 1995, on
education, training and information, states that "co-operatives
provide education and training for their members, elected
representatives, managers and employees so they can contribute
effectively to the development of their co-operatives."  Although
the rigorous training required by many professional and
paraprofessional personnel who are worker-members of, or employed
by, co-operative enterprises engaged in the health and social
care sectors has hitherto been the responsibility of non-co-
operative educational institutions, there are some indications
that co-operative institutions may be beginning to provide such
training.   This may be particularly appropriate in areas which
the co-operative enterprises emphasize, particularly in "healthy-
living" and broad preventive health programmes.  

In Portugal an educational co-operative, the "Higher Polytechnic
and University Education Co-operative" (Cooperativa de Ensino
Superior Politecnico e Universitario (CESPU)), has established
two Higher Institutes of Health Sciences, one in the north, one
in the south of the country.  These provide degree courses, and
also post-graduate and continuing education courses in health
sciences.  212/ 

In the United States, a number of the larger user-owned health
co-operatives, which employ several hundred health professionals
in an increasingly wide range of specialities, have already
entered into agreements with local medical and social care
teaching institutions whereby students and trainees may undertake
residencies.  In Spain the provider-owned health co-operative CES
Clinicas gives particular attention to training in order to
assure quality services to clients.  

A much broader contribution is made by many co-operative
enterprises engaged in the health and social care sectors to
provide training (and not merely information) to members, their
dependents and other members of the community. 

Provision of training to own staff has not been limited to health
co-operatives: in some cases provider-owned social care co-
operatives have given considerable emphasis to training.  For
example, in the United States of America the Co-operative Home
Care Associates of New York believes that training is the
foundation of its high-quality performance, particularly as most
of the worker-members had low formal educational levels.  
Consequently, the co-operative provides new worker-members with
initial training, financed by public and foundation funds. 
Emphasis is on problem-solving skills and co-operative team
building.  Training is provided in English and Spanish.  It is
provided by the Home Care Associates Training Institute, which
has 15 full- and part-time staff.  The core of the training is
a four-week training course for new home-care aides, followed by
four months of on-the-job training that includes site visits from
field supervisors who provide advice and support.  All teachers
were formerly worker-members.  Four times a year worker-members
meet for in-service training sessions in order to keep up-to-date
with rapidly changing methods of providing care to clients. 213/