Health Co-operatives: A Viable Solution to the Current Crisis in Health Service DeliveryCommunity 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bed shortages and too few nurses; of the hardships experienced by people living in rural areas when their doctors have withdrawn their services; of long waits in crowded emergency rooms; of worn-out equipment and not enough new equipment; and so on.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 Newsworlds 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 cooperatives. 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 multidisciplinary 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 cooperative 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 Quebecs 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 centres 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 cooperatives as a way of responding to the wishes of the public and not as a way of questioning the relevance of the governments role in this area; health care cooperatives 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 communitys 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 cooperative 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 cooperative 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 systems 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 multidisciplinary 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 cooperatives 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 cooperative 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 centres 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 cooperatives 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 physicians roles and show its 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 doctors 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 cooperatives a familiar model and raising awareness of the possibilities for cooperatives 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 cooperatives 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 publicall of whom will at one time or another likely be users of health carewould 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: cooperatives 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 cooperative health care, and provide information on health care co-operatives to those unaware of the benefits of the co-operative model. Studies examining the publics 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;

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