Publications
Co-operatives And Health Care
A report to the Secretary of State Andy Mitchell by the minister's advisory committee on co-operatives
Members of the Working Group on Health Care:
Véronique Frigon (Chair)
Jacqueline Mondy
Sam Kean
November 2002
Table of Contents
- Introduction
- Policy Context
- Co-operatives in Health Care: Background
- Features of the Co-op Model
- Research Findings
- Cost-effectiveness of the Co-op Model of Health Care
- Health Care Co-ops in Quebec and Saskatchewan
- Trends in Health Care Co-ops in Canada
- Barriers to Use and Expansion of the Co-op Model
- The Contribution of Co-operatives in Health Care
- Conclusions
- Recommendations
- Health Care Co-operatives: Snapshots
- Community Health Services (Saskatoon) Association Ltd. (Saskatoon Community Clinic)
- Rainbow Community Health Co-operative, British Columbia
- Evangeline Community Health Centre Co-operative, Wellington, Prince Edward Island (PEI)
- Multicultural Health Brokers Co-operative (MCHB), Edmonton, Alberta
- Nor'West Co-op Health & Social Services Centre, Winnipeg
- La Coopérative des techniciens ambulanciers de la Montérégie (CETAM), Montreal
- Coopérative de services de santé Les Grès
- Coopérative de services à domicile de l'Estrie, Sherbrooke, Quebec
- Coopérative d'habitation Beauséjour Saint-Fabien-de-Panet, Quebec
Introduction
Since medicare was introduced in Canada in the 1960s, it has become a cherished program of Canadians. As expressed by Roy Romanow in the Interim Report from the Commission on the Future of Health Care in Canada, "That Canadians feel a profound attachment to their health care system and view it as a defining element of their citizenship is obvious." Co-operatives, which have long played a role in health care, are engaged in the debate now taking place on its future. This report reviews the past and present experience of co-operatives in health care, and offers recommendations on their potential future role.
Policy Context
Following a period of fiscal restraint, most governments are talking about reinvesting in the physical and social infrastructure important to Canadians. Attention has been particularly focused on the health care system, with discussions taking place on how to preserve and modernize medicare, given factors such as competing demands for resources, aging of the population, and new and more costly procedures and medications.
A number of high-profile studies and reports have been commissioned by federal and provincial governments, notably the Commission on the Future of Health Care in Canada headed by Roy Ronmanow. With a final report expected in November, 2002, its mandate is to:
"recommend policies and measures over the long term to ensure the sustainability of a universally accessible publicly-funded health system which offers quality services to Canadians and which strikes an appropriate balance among investments in prevention and health maintenance, and those directed to care and treatment".
The Romanow Commission has already completed several months of public hearings across the country to get Canadians' perspective on what reforms should be made to the health care system. A report released by the Commission, synthesizing over a decade of public opinion on health, notes that Canadians have a strong symbolic attachment to their health care system, and that quality and accessibility are key principles. Canadians acknowledge that money alone will not solve all the problems of medicare, and they are increasingly ready to consider changes in how it is managed. The importance of accountability has increased in the minds of many, while individuals are demanding more say in their own treatment than in the past. Canadians see the promotion of health and wellness as an important goal.
Much of the current debate within government, the media, and the public at large has centred on the "public versus private" issue. A discussion paper commissioned by the Romanow Commission, and written by Raisa Deber of the University of Toronto, attempts to clarify the issue. The paper points out that although about 70% of Canadian health care is funded publicly, it is mainly delivered by private providers, usually not-for-profit ones. The current controversy about "private" delivery is actually about the "for-profit" centres. Co-operative, community-based health centres fall into the not-for-profit category.
Co-operatives in Health Care: Background
Health co-operatives have been a part of the health care sector in Canada since the early 1940s, with the earliest being in the Province of Quebec. A definition used in the Province of Quebec describes a health co-op as "a private, voluntary organization free of political influence and made up of individuals working together to obtain medical services. The organization is based on four principles: team-based medical practice; preventive medicine; periodic payment; and consumer control." 1
Health co-operatives may be started by consumers/clients, producers/workers, or a broad-based combination of the two, using a "solidarity" or multi-stakeholder model:
- User/consumer or client-owned co-operative community health care clinics are set up by people in the community who band together to meet their own health care needs. Such co-operatives are owned by the members. Like other health delivery organizations, they adhere to the principles of free and universal access to services that are paid for by the government. Services outside those funded through public plans may be offered for a fee paid for by users directly or by private insurance plans.
- The co-operative model enables groups of professionals (eg. doctors) and/or other workers (eg. ambulance drivers) to group together to pool resources and achieve efficiencies in their delivery of services.
- Multi-partner, or solidarity co-operatives, aim to meet the needs of different groups of members, such as health care consumers and professionals/workers.
Recent surveys show that in Canada there are some 40 consumer-led co-operative health centres in several provinces, six worker-led ambulance co-ops (all in Quebec), and a small number of other types of worker or professional health co-ops scattered across the country. In addition, there are 42 home care co-ops in Quebec, mainly multi-stakeholder co-ops The great majority of these have been established since 1990.
Features of the Co-op Model
Common features of co-operative community health care clinics include a focus on priority groups, the integration of primary care and health promotion, the importance of community development and community participation, and the use of multidisciplinary teams. These centres normally offer an alternative to the "fee-for-service" model of compensating doctors, based on a salary system.
Health care co-operatives differ from private for-profit sector health care organizations in that the primary objective is accessibility of health care, not the maximization of returns.
Co-operatives are not the only type of community-based model for health-care delivery, and have often served as an example to other community-based organizations. Co-operatives offer some advantages, however, namely:
- they are directly controlled by users or service providers and are accountable to them
- they are able to make use of an established "ready to go" governance model
- they are linked to the broader co-op movement, with the support and sharing of resources and learnings this implies
- they are democratically controlled
- they engage citizens
- the level of community membership, control and accountability is normally more extensive than with other community models
The co-operative organizational model has been used in Canada to ensure that minority language and cultural groups can access health care services in their language of choice. As one example, the Multicultural health Brokers Co-operative in Edmonton, formed by immigrant women, brings together professionals from varied backgrounds (mostly foreign-trained) to ensure that individuals and communities from different backgrounds can easily access needed health and social services.
In addition to these health co-ops, social care co-operatives go beyond immediate primary health care delivery, to provide complementary services such as home care and specialized housing.
Research Findings
The most extensive study of co-operative health care in Canada, "Co-op/Consumer Sponsored Health Care Delivery Effectiveness", by Angus and Manga in 1990, found that co-operative and other community forms of health delivery lowered rates of hospitalization, fostered preventive services, reduced drug costs, and provided higher quality of care than other models.
Other Canadian studies have demonstrated repeatedly that the co-op model engages public participation, encourages self-responsibility, and promotes health.
A United Nations (UN) study in 1997 found that Canadian health co-operatives responded to community demand, and were particularly innovative in providing a wide range of services not available in an affordable form from other types of health institutions. The UN study reported that internationally, health co-operatives are operating in more than 50 countries serving at least 100 million households. These co-operatives operate under many different government regimes and economic and social environments. The co-operative model has thus shown itself to be operationally flexible, and able to fit into diverse environments. Health co-ops are nationally significant in Japan and Brazil, and regionally significant in a number of other countries including Spain and the USA.
The International Health Co-operative Organization (IHCO) of the International Co-operative Alliance maintains that internationally, there is an overall lack of information on health care co-ops.
A current research proposal from the British Columbia Institute of Co-operatives to the Canadian Institutes of Health Research aims to fill in the research gaps on the co-operative health care scene. It would bring together leading academics, health care experts, co-operatives and community-based partners to examine systematically the continuum of health co-operatives, study the political, economic and social context within which each co-op is situated, and provide detailed information to assist policy makers.
Cost-effectiveness of the Co-op Model of Health Care
Studies of the cost-effectiveness of health co-ops have for the most part looked at community-based health care models in general, rather than co-ops specifically. These consumer sponsored health centres are found to be cost-effective relative to fee-for-service practice. In one large study in Saskatchewan involving over 15,000 patients, the per capita cost was 17 percent lower than for other types of practice. The principle reason for the overall cost-effectiveness of the community clinics is the significantly lower hospital utilization rate. Similar findings have been cited in other jurisdictions, and the results have been attributed to earlier recognition and treatment of disease, empowerment of consumers to better look after their own health, and the more integrated, preventive approach used by the centres.
Health Care Co-ops in Quebec and Saskatchewan
The provinces of Quebec and Saskatchewan have the longest experience with health care co-ops, and offer models and lessons from which other provinces could benefit.
Quebec
In Quebec, health care co-ops are involved in five sectors: clinical services, ambulance services, home care, specialized accommodation, and co-ops set up to achieve efficiencies through the group purchase of goods and services. Co-operatives in Quebec have often emerged to deal with a specific problem such as a reduction in public resources, lack of hospital or medical services, or the demand for health services outstripping the supply. They have developed and become successful where government policies have left room for private sector or community involvement, where there is broad community consensus on needs, and where the local community is motivated to take charge and participate in the organization of the work. Co-operative health centres in Quebec have a similar mandate to the publicly-administered Centres locaux de services communautaires (CLSCs), and provide complementary services.
The growing need for home care for an aging population has led to a burgeoning of the home care sector since 1990:
- There are now 42 home-care co-ops, with an annual revenue of over $11 million, employing over 2400 people.
- According to senior staff of the Fédération des coopératives de soins et services à domicile du Québec, the solid rooting in the community, the establishment of partnerships with other health sectors, and the orientation role assumed by the board of directors are three key factors contributing to the start-up and development of this type of co-operative. The larger the co-op (in terms of services sold), the less need for government subsidies. Generally, the firms perform better in rural communities than in large urban centres.
- Even when subsidized, home care co-operatives are beneficial at a public policy level, since they reduce the level of ""nreported work" and improve the quality of work of many people, mostly women, by providing them with steady, better-paying jobs and allowing them to contribute to the government pension fund. Most importantly, they enable seniors to stay at home while delivering quality care and support services to them, thereby reducing the frequency of hospital stays, and the need for nursing home care.
Saskatchewan
In the present context it is perhaps ironic that in Saskatchewan, health care co-ops first developed on an emergency basis in 1962, when many physicians withdrew their services to protest the introduction of Canada's first medicare program. There are now five co-operative health centres in Saskatchewan, serving approximately 80,000 people altogether. Each is tailored to meet the unique and diverse needs of the communities it serves. The centres take an inter-disciplinary team approach to care, using a broad range of health care professionals. The centres also include cultural brokers/community health representatives (eg. for the Aboriginal and cultural minority populations) and work effectively with organizations in other sectors to enhance the social and economic determinants of health (eg. housing, education). The centres have shown considerable success in improving accessibility to services in rural populations. In addition to the full health centres, there are a number of specialist co-operatives (eg. one providing shiatsu therapy) as well as a Community Health Co-operative Federation.
Trends in Health Care Co-ops in Canada
A current project in British Columbia, funded through Health Canada, is raising awareness of the co-op model in rural areas and has led to several start-ups. Demand for information and resources has been much higher than originally anticipated. The project ends in March, 2003. There has also been interest in British Columbia in using the co-op model to run hospitals; this would be a new area for co-ops in Canada if the proponents are successful.
The needs of a growing senior population is of concern in the health care context. Home care is a service which helps seniors and others to live independently in their own homes, with economic and social benefits to both individuals and to society. The development of a large network of home-care co-ops in Quebec provides an example within Canada of the successful use of this model to deal with these emerging needs.
A 1999 publication called the Health Care Co-operative Startup Guide, produced jointly by the Co-operatives Secretariat and co-op sector organizations, has proved a useful reference tool for groups wishing to promote or set up health care co-ops, and for health care professionals and policy makers wishing to learn more about the co-op alternative.
Position of the Canadian Co-operative Movement Regarding Health Care
The Canadian Co-operative Association and Le Conseil Canadien de la Coopération presented a brief to the Romanow Commission in November 2001. The brief built on long-term public policy positions set forth by the co-op sector, encouraging national and provincial governments to maintain the Canada Health Act Principles of universality, comprehensiveness, public administration and portability. It contained a number of other key recommendations including: stressing the importance of minority language services; the promotion of preventive approaches and integrated and co-ordinated interdisciplinary health services; the inclusion of an accountable system of home care within the health system; stronger citizen participation in determining and responding to the health needs of communities; the development of an alternative to fee-for-service remuneration; and the maintenance of the single payer publicly funded system.
The brief highlighted the role played by co-ops in heath care and home care, and stated "We recommend that the Commission advocate for the consideration, support and development of the co-operative organization model of health service delivery as an ideal model for meeting health and social needs in Canada's communities."
During the consultative phase of the Romanow Commission's work, a number of other co-op groups came forward to reiterate the position set forth by the two national organizations. The issue was also discussed in depth at the recent Annual General Meeting of the CCA. There was agreement at the meeting that the co-op model could not solve all the problems in the health care system, but that there are key areas where the model could complement existing delivery mechanisms and improve delivery of services. These areas include home care and long term care, rural and remote communities, strengthening community involvement in health, and strengthening coordination of services between different providers. The issue of co-operative housing was also raised numerous times in the context of addressing determinants of health. Recommendations from delegates included expanding the BC project to other communities in Canada, promoting the co-operative model in home care and long-term care, promoting the development of more health co-operatives through raising public awareness of the model, and supporting and facilitating community discussions about how the co-operative model can be used to provide health services.
Barriers to Use and Expansion of the Co-op Model
The following tables show impediments in a number of areas, and suggest roles for the co-operative sector and government in addressing them.
| Impediments | Role of Co-operative Sector | Government Role |
|---|---|---|
| Insufficient awareness and knowledge of the co-operative model within the health care context. | Use co-op networks and broad-based partnerships to raise
awareness of the co-operative
alternative in health care.
Organize forums and develop relations with the media, promote co-operatives within various constituencies. |
Using existing and new materials,
government should use available
networks and partnerships to help
disseminate information on the
co-op model of health care, and
should support co-op sector
initiatives that promote the
model.
Eg. a Health Canada -supported project in rural British Columbia, undertaken by co-operative sector organizations, has raised awareness of the co-op model, generated considerable interest, and led to co-op start-ups. The project made extensive use of the 1999 Health Care Co-operatives Startup Guide, produced jointly by the Co-operatives Secretariat and co-op sector organizations. |
2. Assistance for Development of Health Care Co-operatives
| Impediments | Role of Co-operative Sector | Government Role |
|---|---|---|
| Lack of information resources. | Work with partners to develop appropriate information resources in a variety of formats. | Facilitate the development of information resources. The development of the 1999 Health Care Co-operatives Startup Guide is an example of a government/co-operative sector collaboration partnership to develop a concrete tool for co-operative development. |
| Lack of experienced and knowledgeable co-op developers to provide technical expertise to those wanting to start health care co-operatives. | Identify existing pool and provide
training for interested parties.
Collaborate at a co-op sector level and with other health care partners (eg. similar community health organizations) to develop expert capacity for co-op development. |
Enhance the capacity of the co-op sector to provide development assistance. Collaborate interdepartmentally and with other levels of government to maximize partnership opportunities. |
| Impediments | Role of Co-operative Sector | Government Role |
|---|---|---|
| Limited, inadequate evaluation of procedures within health co-operatives | Undertaking and supporting research that focuses on evaluating procedures within health co-operatives. | Support and facilitate research by the co-op sector and academics. |
| An inadequate body of knowledge on "best practices". | Work with partners to
identify, document and
disseminate case studies of
successful practices.
Eg. the CCA has contracted with an expert academic at the University of Quebec in Montreal to document examples of successful health care co-operatives in Quebec. |
Support and disseminate
research by sector and
academics, and use internal
research capacity to identify
initiatives and contribute to
sector studies.
Eg. the Co-operatives Secretariat gathers statistical information on various types of co-operatives in Canada, including health care co-operatives. |
| Impediments | Role of Co-operative Sector | Government Role |
|---|---|---|
| Government policies that discourage innovative practices used by health care co-operatives such as alternative payment methods to practitioners. | Identify policies that serve to
create a barrier to progressive
practices, and make
suggestions to government
for change.
Eg. At the 2002 CCA AGM, health care policy was a focus for discussion and debate, and results have been broadly shared. |
Work with the co-op sector to identify policies that hinder innovation, and suggest modifications to ensure that policies support approaches used by co-operatives, such as innovative means of delivering health services. |
The Contribution of Co-operatives in Health Care
1. Cost-effectiveness of the Co-operative Health Care Model
| Issues and Committee Vision | Contribution of Co-operatives | Examples of Achievement |
|---|---|---|
| Governments and citizens
wish to ensure that public
funds are spent cost-effectively.
The population is aging and we expect a relative increase in health costs. "Health care co-operatives differ from private for-profit health care organizations in that the primary objective is accessibility of health care, not the maximization of returns." |
Consumer controlled health
centres have been shown to be
cost-effective. These centres
normally offer an alternative to
the "fee-for-service" model of
compensating doctors, based
on a salary system.
In health care delivery, co-operative and other community-based models have been shown to reduce hospitalization rates, encourage preventive services, lower drug costs and provide a better quality of service than other models. The co-operative model therefore provides overall cost-effectiveness. Particularly innovative is the wide range of services that could not be provided affordably in other types of health institutions. |
A large-scale study of over 15,000 patients in Saskatchewan showed that the cost per person in consumer controlled health centres was 17% lower than in other kinds of practices. |
2. Adaptability of the Model and Responsiveness to the Public's Health Care Needs
| Issues and Committee Vision | Contribution of Co-operatives | Examples of Achievement |
|---|---|---|
| Responding to social
issues by involving
citizens in the solution.
Meeting changing needs and the requirements of different groups in a diverse society. "The co-operative organizational model has been used in Canada to ensure that minority language and cultural groups can access health care services in their language of choice." |
|
Co-operatives have often been
created to respond to a
particular problem, such as
reductions in public resources,
insufficient hospital or medical
services, or a demand for health
services that exceeds supply.
The Community Health Services (Saskatoon) Association was founded in 1962 by physicians and members of the public who were in favour of a public health insurance system. The Association helps and encourages people to play an active role in the health care they receive by participating in health promotion programs and sitting on the Board of Directors. The Rainbow Community Health Co-operative serves the South-Asian community in the Surrey-Delta area of British Columbia. The co-operative is a one-stop health centre with a multi-disciplinary approach to encourage individual and community health, and collaboration within the system. Many of the co-operative's members live below the poverty line. |
3. Trends in Thinking on Health Care
| Issues and Committee Vision | Contribution of Co-operatives | Examples of Achievement |
|---|---|---|
| Moving from treating
disease to promoting
"wellness".
Supporting innovative delivery methods. Responding to changing demographics. Recognizing that broader social factors and conditions have a role in determining the health of citizens (eg. education, housing). "The principles of co-operative health care organizations and the way they operate are consistent with the evolution of thinking generally about the health care system" |
Common features of
co-operative community
health care clinics include
a focus on priority groups,
the integration of primary
care and health promotion,
the importance of
community development
and community
participation, and the use
of multidisciplinary teams.
In addition to primary care, co-operative centres offer a range of other programs and services, such as nursing care, pharmacy, testing and radiology services, optician and optometry services, psychosocial assistance services, programs for the elderly, physiotherapy and occupational services and nutrition services. Some also provide information and training, brochures, audio tapes, videocassettes and CD-ROMs. Social care co-operatives go beyond immediate primary health care delivery, to provide complementary services such as home care and specialized housing. |
The staff of the Clinique Santé
Globale in Montreal embraces new
medical trends, and provides
multicultural services. The
clinic's services range from
traditional treatment to
homeopathy and family mediation,
and include many health-related
disciplines.
In Quebec, there are 42 home care co-operatives with annual revenues of more than 11 million dollars and over 2,400 employees. The Coopérative de services à domicile de l'Estrie, in Sherbrooke, Quebec, a health and home care co-op, founded and managed by seniors, resulted from the desire for a better quality of life through the provision of a complete range of services besides primary health care: housekeeping, repairs, painting, hygiene services, companionship and day (elder) care. Because decisions in the co-op are based on member needs, the organization has earned a reputation for attentive, respectful staff, and constant follow-up monitoring members' satisfaction. |
Conclusions
The principles of co-operative health care organizations and the way they operate are consistent with the evolution of thinking generally about the health care system: a shift from treating disease to promoting health; greater accountability; care tailored to individual needs; innovative delivery models; and greater engagement of individuals in their own health care.
The model has shown itself to be cost effective, and to respond to the evolving needs of individuals and communities; whether those of culturally diverse populations, or the growing numbers of seniors, or the special challenges of rural communities.
Given the relatively small number of co-operative health centres in the country, there appears to be potential for expansion of the model. Co-ops can also be used for complementary services, such as home care (becoming increasingly important) and to address the broader determinants of health (eg. housing). With increased awareness of the co-op model, and information and resources for co-op start-ups, the successful experience of co-ops in certain regions could be replicated, and new approaches tried. Further research is needed to document successful practices of health care co-ops, and to analyse in what circumstances the co-ops work best.
Recommendations
- The co-operative model for health care should be recognized as an exemplary model of community-based, citizen centred service delivery in the health care field.
- All levels of government and the co-operative sector should collaborate to raise the visibility of the co-operative health care option.
- Governments should ensure that their policies encourage innovative means of delivering health services (eg. community-based models focussing on the promotion of wellness, alternative payment methods, team-based approaches).
- Research showing how and when to best use the co-op model in health care should be supported.
- Adequate resources and assistance should be available to help people who wish to start up co-operative health care organizations.
- Home care should be recognized as an essential component of the health care system, and the co-operative model of home care promoted.
- Co-operative approaches that address the broader social and economic determinants of health should be supported (for example, housing).
Health Care Co-operatives: Snapshots
1. Community Health Services (Saskatoon) Association Ltd. (Saskatoon Community Clinic)
Community Health Services (Saskatoon) Association was founded in 1962 by pro-medicare doctors and citizens. The Association sponsors the Saskatoon Community Clinic, and has approximately 5500 member households representing close to 10000 adult members. Most members live in Saskatoon and the surrounding rural areas. The Association encourages and assists individuals to play a role in their own health care by participating in health promotion programs and serving on the Board of Directors. The organization also speaks out and acts on social and economic issues that affect health, including the effects of poverty, environmental issues, and smoking.
In addition to the services of family physicians, the clinic offers a broad array of other programs and services including nursing, pharmacy, laboratory and X ray, optometry and optical, counselling, seniors' programs, physical and occupational therapy, and nutrition. The clinic also carries informational and instructional books, pamphlets, audio and video tapes and CD roms.
2. Rainbow Community Health Co-operative, British Columbia
The Rainbow Community Health Co-operative was launched in February, 1998, with a mission to "provide a wide range of medical services to people so they will be encouraged and enabled to follow healthy habits through culturally sensitive education and promotion of preventative practices". The co-operative serves the South-Asian community in the Surrey-Delta area of British Columbia, directly addressing itself to a number of key issues including substance abuse, prenatal care, HIV/AIDS, diabetes, heart disease, cancer prevention, depression, family violence and dental care. The co-operative is a one-stop health centre with a multi-disciplinary approach to encourage individual and community health, and collaboration within the system. Many of the co-operative's members live below the poverty line.
The co-operative is continually expanding its reach and working with partners to offer a full range of related programs and services. Beyond the provision of community-based health care, the co-operative acts as an outreach program, distributing information on a broad variety of subjects and taking on a life of its own within the community. Recognizing the particular needs of the growing population of seniors, the co-operative has recently developed a Seniors Multicultural Housing project.
3. Evangeline Community Health Centre Co-operative, Wellington, Prince Edward Island (PEI)
This health co-operative in the Evangeline region, a small Acadian community in the south-west of PEI, came about when local residents tried to fill the gap created by the retirement of the local doctor. After studies and a survey were undertaken, the co-operative was founded in 1977. The co-operative has been successful in attracting bilingual medical services, and was chosen by the Province as a pilot project site for the establishment of a community preventive health centre in the region. The co-operative has earned an enviable reputation for its ability to meet the needs of various segments of the population. The Evangeline region has been called "the uncontested co-operative capital of North America" and a network of interrelated co-operatives has shown that communities that are being marginalized can take matters into their own hands and succeed in providing services to the population using a bottom-up approach, where externally driven development has failed.
4. Multicultural Health Brokers Co-operative (MCHB), Edmonton, Alberta
The co-operative was formed in 1999 by immigrant women who knew first-hand the difficulties faced by immigrants in obtaining needed health services. The organization serves culturally diverse communities, including immigrants and refugees, and helps them gain access to health services and social supports within the context of their language and culture. The worker members are mostly foreign-trained professionals such as medical doctors, nurses, computer analysts, graphic artists, and teachers. The MCBH offers social, emotional and informational support to immigrant and cultural minority families, and provides prenatal education, parenting classes, hospital tours, support groups and community development projects. An integral part of the MCBH is support for policy development. Various organizations and health institutions contact the co-operative for its input into hospital policies and cross-cultural health issues.
5. Nor'West Co-op Health & Social Services Centre, Winnipeg
It costs one dollar to belong to the Nor'West Co-op Health & Social Services Centre. The centre offers a wide array of integrated programs serving people of all ages. Primary care services include pregnancy testing and pre-natal care, a well baby clinic, immunizations, fitness assessment, and family planning. Health promotion programs include a women's support group, parenting groups, and adolescent health. A Well Elderly Health Promotion program includes nutrition awareness, senior fitness, crafts, Wheels to Meals, and low impact aerobics. Because of the importance of mobility to physical and mental health, a feature of the co-operative is a foot care program for seniors. Child care services are also integrated into the co-operative's programs, including care for children with disabilities.
6. La Coopérative des techniciens ambulanciers de la Montérégie (CETAM), Montreal
Located in the south shore region of Montreal, CETAM is a worker co-operative of ambulance workers, serving 70 municipalities. Ambulance co-operatives such as CETAM provide 30% of all ambulance service in the province of Quebec. There are six ambulance co-operatives in the province; two in the lower St. Lawrence region, and one each in the regions of Quebec City, Mauricie, the Outaouais, and Montérégie. In 1999, according to their annual reports, five of the co-operatives represented 533 worker members, and 626 other employees. Their revenue equalled $34.7 million.
7. Coopérative de services de santé Les Grès
Prior to 1995, the people of Saint-Étienne-des-Grès, a small municipality near Trois-Rivières, had been without doctors and pharmacists to provide health care and related services locally. The residents decided to join together to put in place the infrastructure required for the services they needed. The co-operative, which has 1,300 members, has been in operation since the end of 1995. The experiment is the first of its kind in Quebec, with citizens combining forces to create, through their own investments, a health services co-operative that has become an independent local tool for all its members in all areas connected with health. In addition, the co-operative has formed a co-operative education committee and has, through internal management regulations, made it obligatory to produce a development plan each year with respect to prevention of health problems.
8. Coopérative de services à domicile de l'Estrie, Sherbrooke, Quebec
This health and home care co-op, founded in 1989 and managed by seniors, resulted from the desire for a better quality of life through the provision of a complete range of services besides primary health care: housekeeping, repairs, painting, hygiene services, companionship and day (elder) care. The co-operative has 750 members and 30 employees, and demand is growing. Because decisions in the co-op are based on member needs, the organization has earned a reputation for attentive, respectful staff, and constant follow-up monitoring members' satisfaction.
9. Coopérative d'habitation Beauséjour Saint-Fabien-de-Panet, Quebec
This example shows how the co-operative model of housing can contribute to community development, and be integrated with health care provision, for the benefit of resident members and the community at large. Recognizing that the small town of Saint-Fabien-de-Panet had an acute shortage of affordable housing, the 15-year-old Coop Beauséjour decided to expand by buying houses that older people could no longer maintain. This new phase of the co-op offers housing and other facilities for young families and for people with mental illnesses. Led by a dedicated professional in the membership, the co-op bought and renovated 15 houses. Beauséjour also signed a service agreement with an agency that would screen, help and monitor the members with mental illnesses. Besides these special-needs members, the expansion has benefited older people who were finally able to sell their homes, young families, local building trades and other businesses, and the community as a whole, which had been at risk of losing such vital services as its schools.
