Health Co-operatives: A Viable Solution to the Current

Crisis in Health Service Delivery

Community involvement is vital to the co-operative model. How to involve

people from the community is an issue faced by most co-operatives.
Communities will come together against a perceived threat to their
neighbourhood, but often lack the same motivation for something that is a
positive addition to the community. Communities that feel disadvantaged
or marginalised may want to become involved to change their situation.
Interest, however, can fade and it is important, for the success of the
centre, to maintain interest and involvement over time. Communities that
become involved in health co-operatives will have the benefits of
appropriate services, feelings of pride and empowerment, and a sense of
control over their health service. - Kristen Sinats

Kristen Sinats
University of Victoria, British Columbia Institute for Co-operative Studies

Introduction

The Canadian media frequently reports of a “crisis” in the Canadian health care
system. News stories have told of people waiting months, and sometimes years,
for elective surgery; of cancelled life-saving procedures because of hospital bed
shortages and too few nurses; of the hardships experienced by people living in
rural areas when their doctors have withdrawn their services; of long waits in
crowded emergency rooms; of worn-out equipment and not enough new
equipment; and so on. The media has also reported on proposed solutions to the
so-called crises. For example, proponents of private (for profit) health services
claim that allowing people the option to step to the front of the line, by paying for
the service they need, can ease the burden on the public system; doctors' groups
maintain that paying doctors more money will help solve some of the problems;
nurses insist that training many more nurses is crucial to a well-functioning health
care system; other groups contend that the whole health care system needs a
complete overhaul; and so on. In fact, CBC Newsworld’s television program,
Counterspin, recently (January 30, 2001) provided the venue for a lively debate
on the state of health care delivery and ideas for improvement. Media portrayals
of the state of health care were hotly contested and the participants did not agree
on health care solutions; however, everyone who spoke agreed that there is a
need for change. What the changes should be and how to implement them were
further points of dissension. Many of those who spoke, particularly those
opposed to 'two-tier' health delivery, argued for a marked ‘shift’ in the way health
care is organised, practiced, and delivered. Disagreements and rhetoric aside,
crisis or not, it is probably accurate to say Canadians are concerned about health
care.
Issue

Outside of the hype of media, there is considerable evidence that our current
health care system, while exemplary in some areas, needs improvement in
others. What is really wrong with our health care system and how can it be
changed so that it is improved, if not fixed? Some advocates for change maintain
that the current problems range from the overuse of acute care beds to the
absence in the system of both prevention and health promotion activities. Some
critics contend that health policies, to their peril, have ignored the social and
economic determinants of health such as poverty, education, and social support.
Instead, the current emphasis on high technology, acute care, and short-term
solutions are detracting from sustainable long-term solutions that, over time,
could have a significant, positive effect on our health care system. In 1996, the
Community Health Co-operative Federation stated that “[t]he mass of provincial,
national, and international health intervention outcome studies have irrefutably
demonstrated that our current individualfocused, illness based, treatment
orientated health system is both ineffective and too costly” (p. 8).

Community Health Model

There are many people in Canada who concur that changes to health delivery
services are necessary, yet discussions of ineffectiveness and high costs have
led to few practical, long-term solutions. An exception and a promising alternative
to the status quo is the community health model. This model has proved
successful in a number of provinces including Saskatchewan and Quebec; it
could be considered a key strategy towards solving the ‘crisis’
in health care.

Many sectors of health care would benefit from one kind of community health
model: the health co-operative. There are many models for a health co-
operatives. However, the user or client-owned model found in Canada is
characterised in the following way:

User- or client-owned health co-operatives are set up by individuals in the same

community to help them meet their own health care needs. Member-users
determine goals and practices, thereby enabling ordinary citizens to empower
themselves with respect to health care. Members and owners each contribute
shares of capital and subsequently contribute to operating costs, usually by
prepaid premiums, and appoint managers to negotiate contracts with health
insurance and health care providers. Often these co-operatives purchase and
operate hospitals and other facilities, and hire professional and other staff.
Services range from simple preventative care and basic insurance to advanced
curative and rehabilitative interventions (International Co-operative Alliance,
Website).
For example, primary-care co-operatives, as the first point of contact for health
services, offer a range of primary health care and social services. According to
Michael Rachlis (2000), primary health care is best delivered through multi-
disciplinary centres, which act as vehicles for the delivery of a variety of
communitybased services. Groups such as women, seniors, aboriginal persons,
and people living with disabilities could be served better by a health co-operative
because, as members and active participants in the goals of their co-op, they can
have attention paid to their special needs (Co-operatives Secretariat et al., 1999).
In addition to primary care, cooperatives can be structured to provide hospital
services and health insurance. Co-operative hospitals can be created through the
joint effort of community members, concerned with maintaining hospital services
and health professionals, employed by hospitals. There are successful examples
of these co-operative practices, such as the network of rural hospitals in
Wisconsin (see www.rwhc.com), and Pacific Blue Cross, a health insurance co-
operative that provides insurance services at competitive rates.

'Although the co-operative model has been a part of the health care sector since
the early 1940s, never have Canadians and political leaders shown as strong a
desire as in recent years to consider alternative means of providing health care
services.' (Co-operative Secretariat et al.,
1999, p.17) There are examples of well-functioning models of various types of
health co-operatives in Canada and the United States. Ambulance workers in
Quebec have successfully formed a workers’ co-operative. Saskatchewan
pharmacies are part of a co-operative data network. Saskatchewan and
Manitoba have primary health care co-operative centres that have been in
operation for many years. The National Co-operative Federation governs the
primary health centres in Saskatchewan.

In the remainder of this paper, I describe models of primary care cooperatives

and community health centres. I also discuss the strategies that are needed to
incorporate these approaches within the health care system.

Background Information In Co-op/Consumer Sponsored Health Care

Delivery

Effectiveness, Angus and Manga (1990) outline three models of community

participation in health care and how they manifest in the various centres and
organisations providing health services. The three models are the following:

♦ the community participation model, which includes Community Health Centres,

Co-operative Health Centres, and Quebec’s Local Community Services Centres
(CLSCs);

♦ the quasi-community participation model; which includes Health Services

Organisations, Health Maintenance Organisations, and Multi-Service Centres;
and
♦ the minimal participation model, which includes Hospital Affiliated Ambulatory
Care Centres, and Physician Based Ambulatory Care Centres.

Common features of community health centres, functioning in Canada, as well as

internationally, consist of a focus on priority groups, the integration of primary
care and health promotion, and an emphasis on wellness, the importance of
community development and community participation, and the use of
multidisciplinary teams. Community Health Centres that follow the co-operative
model are non-profit organisations, owned and operated by the members who
use their services. Members elect a board of directors who govern the centre.
Each member has one vote, regardless of the number of shares held by the
member. Members and users are involved in defining the centre’s mission,
mandates, goals, and the types of services offered (Lapointe, 1996). “Community
participation can be facilitated through Board representation, committees of the
Board, development of needs assessment, satisfaction surveys, fundraising,
volunteer involvement etc.” (Angus & Manga, 1990, p. 20). Health co-operatives
support the principles of the Canada Health Act, which states that health services
should be universal, accessible, comprehensive, portable, and publicly
administered.

Community Health Centres that are not co-operatives provide similar programs
and services as a co-operative, but the level of community membership and
control is not as extensive. Health co-operatives are multi-disciplinary centres
that offer a range of services with a primary focus on health promotion and illness
prevention, which incorporates health determinants including poverty, education,
and environment. Clinics offer services that include primary care, health
promotion, seniors’ health programmes, and social services. Primary care
services provided by a health co-operative include family practice, well-baby
programs, and immunisations. Massage therapists, chiropractors,
physiotherapists, and nutritionists work as part of a multi-disciplinary team in
some centres. Health promotion services can include support, parenting, and
moms’ and tots’ groups.

Meals on wheels, flu shots, and home care are valuable senior services 'Health
co-operatives
support the principles of the Canada Health Act, which states that health services
should be universal, accessible, comprehensive, portable, and publicly
administered.' provided by community health centres. Many health centres have
partnerships with other organisations and sectors; this arrangement allows them
to offer social services, such as health education, economic development,
referrals, and mental health services (Lapointe, 1996).

The co-operative movement in Canada “ views the creation of health care co-
operatives as a way of responding to the wishes of the public and not as a way of
questioning the relevance of the government’s role in this area; health care co-
operatives would give the public better access to and control over health services
and would foster partnerships with public agencies” (Cooperative Secretariat et
al., 1999, p. 16). The public's changing attitudes regarding health care have led
to a growing demand for a system that allows consumers to participate in their
own health care and to have control over the services being offered in their
region.

Community Participation

Co-operatives rely on participation by members of a community. “Community

action (and organisation) for growth and change, as opposed to community
development, denotes active participation and ownership of planning from
conception to the implementation of a project” (Wharf, 1997, p. 206). Community
health involves the community at various levels in the provision of health care.
“More citizen participation and more opportunity for patients to influence the
delivery of services could lead to better care”(Rachlis & Kushner, 1994, p. 275).
The concept of Healthy Communities, as articulated by the World Health
Organization, is based on social epidemiology, community empowerment, and
grassroots activism. It emphasises the identification of social and environmental
factors that affect a community’s health and well-being (Kinder et al., 2000).

Some community health centres provide programmes and services to targeted

groups that have accessibility difficulties, for example, people in remote
communities, people with low income, the elderly, and immigrants. This includes
people from various cultural and linguistic backgrounds for whom language and
cultural differences are a barrier to use of the health system. The Rainbow
Community Health Co-operative, in Surrey, British Columbia, is an example of a
clinic with an emphasis on immigrant and visible minority populations. “Lack of
access to culturally appropriate services may lead to serious physical and
psychological consequences as well as over-medication, unnecessary
hospitalization, and increased use of medical services” (Liotta, 1997, p. 7). A
guiding principle of the Rainbow Co-op is to provide culturally appropriate
services to the large immigrant population in their region by reducing barriers,
such as language and cultural differences and addressing specific health
concerns where gaps in services may exist.

In 1996, there were 30 co-operative health centres in Canada: three in Prince

Edward Island, seven in Nova Scotia, seven in Quebec, four in Manitoba, five in
Saskatchewan, two in Alberta, and two in British Columbia (Lapointe, 1996). In
Saskatchewan, in 1963, communities, concerned about the loss of health
services due to a threatened doctors’ strike, came together and formed a network
of co-operative health centres. “There are currently five health care co-operatives
offering community based medical, (which includes day surgery, pharmacy,
ophthalmology, etc.) rehabilitative and health promotion services to 17,000
members and 85,000 users in Saskatchewan” (Co-operative Secretariat et al.,
1999, p. 17).
Although they are not formal co-operatives, the centres in Sault Ste Marie and
Quebec operate on co-operative principles. In Sault Ste Marie, steelworkers,
concerned about accessibility to health services, formed the Sault Ste Marie and
District Group Health Association. “Local community service centres (CLSCs) in
Quebec developed from grass roots activism and the “whole person” approach to
health during the Quiet Revolution in the 1960s” (C.U.PE., 1995, p. 8). CLSCs
are integrated centres that provide health services, social services, and
community organisation. Community control and public involvement is important
for both the health and the empowerment of Canadian citizens.

Advantages of Health Co-operatives

Co-operatives should be viewed as a complement to the current system, not a

replacement. Robinchaud and Quiviger (1991) state: In 1984, a national task
force on the development of co-operatives in Canada made some
recommendations concerning health co-ops. At the conclusion of its study the
task force concluded that the cooperative model could provide an appropriate
approach towards rethinking organisational forms for the delivery of some health
services. This model could, in particular, apply to community health or social
service centres or to multi-service community centres using an integrated
services model. (p. 191)

As mentioned above, a wide range of services are offered at a community health

centre, including health promotion and illness prevention. Users of a health co-
operative pay a minimal fee to join the co-operative. Co-operatives know who
their members are and, presumably, what services would best meet their needs.
Co-operative members help determine what services and programs should be
offered. As the continuing care of chronic diseases becomes a concern in
Canada, health care organisations that can identify their practice population and
hence evaluate the success of clinical strategies in providing more effective care
will contribute to the improvement of health care services. A comprehensive
knowledge of the member/user population allows the health centre/health co-
operative to plan for future funding needs and services or programs that should
be offered.

There are significant advantages to building consumers and communities into

decision-making and governance structures. The community health centre
movement has long recognised that because citizens have a tangible stake in the
quality and usefulness of health services, they are both valuable resources (for
example, in identifying needs) and helpful participants (eg., in developing
programs).

Community control can also enhance the system’s ability to innovate at the local
level, adapt to local needs, and develop programs that integrate health and social
services. (BC Nurses Union et al, 1999, p. 19) There are several examples of
centres in British Columbia that encourage community involvement and have
structured their programs to benefit the people who use them. Examples of these
are the Reach Community Health Centre in Vancouver, and the James Bay
Community Project -- Health Services, which is located in Victoria.

A further advantage of a health co-operative is its employment of a multi-

disciplinary health team – this allows health care users the convenience of
having all services in one location. “There is a growing consensus within Canada
that primary care services can and should be delivered by a range of providers,
including but not limited to physicians” (C.U.P.E., 1995, p. 16).

For people living in rural areas or people living with disabilities, who currently
have to travel to various locations for required health services, this arrangement
is especially advantageous.
This multidisciplinary team structure engenders a supportive working atmosphere
and, it could be argued, improved care of the patients. Rather than a fee for
service, members of the team get paid a salary; among other advantages, a
salary allows physicians to spend more time with their patients, when it is
necessary. Angus and Manga (1990) summarise the benefits of the community
and quasi-community models of health care:

♦ they have lower rates of hospitalization of their patients;

♦ they are better structured to provide preventive services to their patients;

♦ the physicians are more likely to believe their remuneration method is

conducive to the delivery of preventive services;

♦ the lengths of stay in hospital are lower for their patients;

♦ the drug costs are lower; and

♦ there is evidence that some models provide higher quality of care. (p. 28)

These benefits appear to address many of the major ills of the ailing health
system.

Barriers to the Implementation of Health Co-operatives

It appears that the co-operative model has many advantages and could be a
viable option for providing health services. Though the value of community health
centres seems to be recognised by many people, the community health model
has yet to be seriously considered, as a practical option for health care delivery,
by the majority of policy-makers and health delivery people. There are several
reasons for this lack of consideration: insufficient awareness and knowledge of
the co-operative model, difficulty obtaining medical professionals to work in the
centres, poor evaluation procedures of the health co-operatives, and the absence
of legislated legitimacy. There is a paucity of literature documenting the success
and failures of health co-operatives; a systematic and rigorous gathering of
information that would contribute to a meaningful analysis and practical outcome
is needed.

Another reason for the slow growth is resistance from the medical profession.
Many doctors prefer to be self-employed and to work on a fee for service basis
rather than on salary. In the past, doctors have been reluctant to practice in co-
operatives in the health sector. For example, when the clinic in Sault St Marie
was formed, doctors questioned the absence of evaluative procedures and were
concerned about the intrusion into the doctor/patient relationship.

Occasionally, as the following example illustrates, medical professionals,

concerned about alternative health organisations, choose to voice their
objections rather than work with the centres to address their concerns. In
Saskatchewan, during the 1960s, the College of Physicians attempted to prevent
the centres from advertising and to restrict the hospital privileges of physicians
employed by the centres (Lomas, 1985). Gruending (1974) recalls that “informing
health consumers of available services was construed by the college as
advertising for patients, unethical medical conduct” (p. 18). Clinics, today,
continue to struggle with restrictions on advertising.

Education and Increasing Awareness

Education plays an important role in the development of co-operatives. A better

understanding of the model will help to reduce the barriers new cooperatives face
and will help to encourage others to consider this model when planning health
care delivery systems for their communities.
Medical Providers There is no doubt that physicians provide important medical
care for their patients; nevertheless, in the interests of improving health care, it is
important to seek out improvements to practices. “Physicians and other care
providers need to work in multidisciplinary teams, sharing decisions about care
practice. It is important to give physicians a role beyond that of fee for service
practitioners, but more than their payment structure needs to change”(BC Nurses
Union et al, 1999, p. vii). Education in medical school continues to focus primarily
on traditional methods of treating patients rather than promoting the benefits of
health promotion and working in multidisciplinary teams. “As the health care
system changes, educators need to redesign the curriculum to train health care
providers so that they can work in multiprofessional teams and deliver community
based, primary and preventive healthcare”(Talen et al., 1998, p. 213). Health co-
operative settings could provide the opportunity for doctors to work as part of a
multidisciplinary team in an integrated centre. “Community health centres
affiliated to teaching hospitals could expose medical students to the alternative
approach when their medical values are forming” (Lomas, 1985, p. 159).
It is essential for healthcare providers to have a thorough understanding of how a
co-operative health centre operates, the centre’s principles and mandates. “The
CHC philosophy is different from the medical model, and it is difficult for some
people to accept notions such as community boards, sharing responsibility with
other health disciplines, and shifting emphasis towards prevention and health
promotion”(Lewis, 1991, p. 9). Insufficient knowledge of co-operatives, how they
operate and how the model can be applied to health care is not limited to the
medical profession. “The public is generally unaware or not overly concerned
about alternative delivery systems and that they can have a role or influence the
nature and design of the care available to them” (Angus & Manga, 1990, p. 39).
Public interest in alternative delivery systems has increased, but there continues
to be conflicting information about alternative or additional delivery systems. It is
primarily consumers’ responsibility to sift through the information on their own.

Public / Users

There has been limited research and evaluation of health co-operatives in

Canada. In particular, there is the question: how can the public contribute to
finding a solution for the continuing crisis in health care? Marketing, promoting,
and educating the public about community health centres and cooperatives is
necessary. The co-operative sector can contribute to public education by making
co-operatives a familiar model and raising awareness of the possibilities for co-
operatives in the community. It is important for the public, medical professionals,
and policy makers to be well informed about the many advantages that can be
offered by a community health center. “There are several things the public needs
to be aware of, they need to know what the alternatives are, the models they are
based on, the benefits or disadvantages and how to become involved”(Canadian
Council, 1985, p. 64).

Community involvement is vital to the co-operative model. How to involve people

from the community is an issue faced by most co-operatives. Communities will
come together against a perceived threat to their neighbourhood, but often lack
the same motivation for something that is a positive addition to the community.
Communities that feel disadvantaged or marginalised may want to become
involved to change their situation. Interest, however, can fade and it is important,
for the success of the centre, to maintain interest and involvement over time.
Communities that become involved in health co-operatives will have the benefits
of appropriate services, feelings of pride and empowerment, and a sense of
control over their health service.

Policy Makers

The political will to set up more CHCs clearly exists. The CHC system has to
refine the duties of its lay boards, clarify physician’s roles and show it’s offering
unique services. And organised medicine will have to respect the free choice its
members make, recognising and supporting those who feel that working in a
CHC is a fullfilling way to practice medicine. (Morgan & Cohen, 1991, p. 768)

Policy makers need to be provided with more information about the advantages
of alternative organisations of care. Case studies, outcome research, lists of
health co-operatives, and evaluation frameworks would contribute to raising the
policy makers' awareness of co-operatives. In Saskatchewan, the Community
Health Co-operative Federation Limited (1996) recommended that the
government work with community clinics to achieve the following objectives:

♦ to develop legislation to protect our model;

♦ to evaluate our model to ensure it provides primary health care effectively,

efficiently, and economically;

♦ to determine and act on what can be done to improve our model; and

♦ to inform the general public and District Health Boards about our model, so
they can consider adopting the elements of it that can improve health care to the
people of their communities.(pp. 13)

Health co-operatives need to become part of the discussion on how to improve

Canada's health care system. Again, the co-operative sector could aid in raising
awareness and offer suggestions as to how a co-operative model may best be
applied to the current system.

Policy Implications

Legislation
A further reason for the limited growth of health co-operatives is the lack of
legislated legitimacy. “The lack of definition, goals and objectives has confused
practitioners and administrators and led to complex bureaucratic procedures
which make it difficult to establish new centres and expand existing ones”(Angus
& Manga, 1990, p. 38). Health co-operatives have suffered from an “image
problem”(Angus & Manga, 1990, p. 39 ). They are often viewed as medicine for
low income citizens. Legislated legitimacy would give consumers confidence that
the services being provided in a health center are equal to and more
comprehensive than those being offered in a private doctor’s office.

Legislation may lead to political commitment to assist and develop community

health centres. “Governments need to put into place a legislative and financial
framework that is conducive to the development of health care co-operatives and
consistent with the principles of Medicare” (CCA, 1989, p. 26). Specific legislation
is needed that defines the role of health care cooperatives and their
organisational and financial structures. The literature on health co-operatives is in
agreement about the need for legislated legitimacy to aid in the future
development of co-operatives in the health sector.

'The co-operative sector can contribute to public education by making co-

operatives a familiar model and raising awareness of the possibilities for co-
operatives in their community.'

Evaluation

Appropriate evaluation frameworks need to be designed and implemented. It has

primarily been the responsibility of the community health centres to prove their
value. Few case studies have evaluated health cooperatives, their impact on the
local community, how and why they were formed, and the effect their presence
has on other health providers. “An analysis that satisfactorily incorporates the
differential levels and kinds of needs of the patients served by the different health
care delivery modalities has not been undertaken” (Angus & Manga, 1990, p.
33). Co-operatives are frequently evaluated in comparison to the practice of fee
for service, rather than other community health models. “Since health care co-
operatives often have a medical focus different from that of fee-for-service
practice (preventive, rather than simply curative), the different criteria by which
they should be evaluated needs to be recognised in legislation”(CCA, 1989, p.
26).

Proposed Solutions for Raising Awareness:

In order to advance the possibility of co-operative health organisations, strategies

need to be developed to increase awareness of what co-operatives are, how they
fit with the current system, and the advantages they offer as one solution to the
current problems in the health care system, particularly in those areas most
affected by a lack of access.

Resource kits that provide information on health co-operatives should include the
following:

• information on existing health co-operatives;

• literature on health co-operatives;

• ideas of how to implement a co-operative;

• the benefits of the co-operative model; and

• characteristics of ideal communities for implementation.

The British Columbia Institute for Co-operative Studies is well-placed to both
compile such a resource package, and to make it available to the government, to
health professionals, and to the public in general.

Furthermore, an advocate for the lesser-known ideas about health communities

and alternative models of health-care delivery is needed. Again, the relevance of
organisations, such as the BC Institute for Co-operative Studies, which engage in
action oriented research, needs to be underscored.

Keeping in mind the different levels of interest (or disinterest) held by the public,
skilled educators could design informative programmes for presentation at
various popular public venues. The public—all of whom will at one time or
another likely be users of health care—would then have the opportunity to learn
informally about possibilities for effective and meaningful health-care delivery.
This kind of educational process fits well with co-operative practices: co-
operatives are member-initiated and driven, which means it is incumbent on
interested persons to determine their particular needs and goals. However,
because there seems to be a dearth of information and knowledge about
cooperatively organised health, providing this information is a necessary step.

Following these promotional activities are other important steps that need to be
taken if we are to at least consider the co-operative health possibility. Providing
community needs assessments is an important step. These assessments would
help determine those communities wishing to change how health care is provided
in their area. They could also identify the communities already interested in co-
operative health care, and provide information on health care co-operatives to
those unaware of the benefits of the co-operative model.

Studies examining the public’s attitude towards both using and developing health
co-operatives also would be beneficial; certainly these kinds of studies could be a
significant factor in promoting co-operatively organised health care among health
professionals and policy makers.

Recommendations

In summary, the following recommendations are suggested to further the

acceptance and implementation of community health co-operatives:

♦ Develop clear definitions, goals, and objectives as the basis for new centres
and the expansion of existing ones;

♦ Develop a legislative and financial framework to encourage legislated

legitimacy;

♦ Redesign the curriculum in medical schools to incorporate the benefits of health

promotion, preventative health care, and working in multidisciplinary teams;
♦ Educate the public and “users” of the health system as to the benefits and
disadvantages of the current and alternative models of health care;

♦ Provide policy makers with evidence of the advantages and possible

disadvantages of co-operatives, through case studies, outcome research, and
evaluation;

♦ Develop evaluation frameworks that are consistent with the philosophy of a

community health model.

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