To mark the closure of the International Year of Co-operatives, jointly organised by the United Nations and the International Co-operative Alliance, Compartir magazine interviewed the president of the International Health Co-operatives Organisation allowing him to express his ideas on the present and future of the movement. (Click here to read the original interview at Compartir magazine)
How would you describe the current situation of international health care?
When we talk about health we tend to do so from a local perspective, believing that our reality both unique and universal at the same time, when the truth is that we are faced with a wide range of different scenarios, which are not exclusively dictated by political and economic contexts, although they are clearly influenced by such factors. The fact is that we typically talk about health in terms of “our” take on reality. And this is probably not only understandable, but is the way things should be. In other words, the concept of health should be identical and universal worldwide.
The fact is, though, there are too many variables to take into consideration, even in apparently equivalent systems or those which enjoy a halo of excellence, which does not always correspond to the situation which ultimately exists in each particular location or setting.
The attempts made by most international organisations with interests in this field tend to focus on equivalence in the term “health”, rather than “health care”, in the sense of systems which cover aspects of both provision and prevention.
And so we should perhaps be talking about the spectrum of “health care realities” and their different focuses, since national health systems, as we understand them in Europe, do not exist all round the world, and even in our most immediate context they are not all similar.
It is not enough to talk about the differences between the North American, European or South American models and the huge variations between developing countries and those we refer to as developed, nor those which are fully engaged in the process of evolution, all the more so given the recently added variables, with the risks inherent in possible failures in options which are apparently more or less consolidated, without overlooking situations of poverty or exaggerated satisfaction with apparently consolidated sustainability.
In what other ways could one treat the question given the current context of crisis?
By being aware that there are alternatives to the tried and tested methods. At least there is one of which I am in a position to speak: co-operative medicine, as championed by the Espriu Foundation. Medicine which proves itself to be effective in any economic context in the world. The debate is more necessary than ever, and a failure to consider every shade of opinion would be a serious lost opportunity. There are, fortunately, exceptions, such as a number of leading trade union experts and many other figures in the health economy who have put forward clear ideas thus helping clarify the main points of debate. Unfortunately, though, all too often information is released providing opinions revealing opinions with little analysis or foundation behind it, preventing a serious debate from taking place. But the playing field is one which lends itself to populist debate. I regret the loss of institutional values, in particular within the current crisis. What we need is to reach wide-ranging agreements on priority issues: governments and the parties which support them need to look beyond their individual interests and to minimise local influences for the sake of the common good. We need the broadest possible unity to deal with such a crucial issue as health care. For many years now the Espriu Foundation, together with a huge number of other social actors, has been calling for a Health Care Pact at the national level in all countries. It is, though, something which has been talked about for a long time, without any progress being made. I was trained in the school of Gregorio Marañón, who in his day knew how to put the public above the narrow interests of any individual party. Adopting the same learned approach as him, we today need a global pact with a social perspective. Dr Espriu shared the same vision: when he set about promoting health co-operatives he was concerned not with the corporate interests of doctors, but a global, social interest in improving health care and placing the doctor-patient relationship at its heart.
Do you, then, view the current situation with optimism?
My perspective is that of the co-operative movement, an optimistic perspective both locally and also nationally and internationally. Understandably optimistic, I would even say. Because we have seen the power of the co-operative movement at the start of this decade which we are calling the “Co-operative Decade”.
Today’s leading economists highlight what Dr Espriu said to the International Assembly of the International Co-operative Alliance held in Québec back in 1999, within the context of debates between capitalism and socialism: “The third way is the co-operative way”. I never tire of saying the same thing to all the forums I attend, a few days ago it was the WHO: the co-operative model is as valid in developing countries as in developed countries. Sweden offers a paradigm. The co-operative decade urges us to rethink the current situation and consider alternatives.
What position does the Espriu Foundation hold on the international stage?
The Espriu Foundation is the world’s fourth-largest health care co-operative, according to the report recently published by the International Co-operative Alliance (ICA). It should be pointed out that the two largest are consumer co-operatives in the United States: a different market, a different setting, a different legal framework. The third is also in the US, a sports health products co-operative which includes health care. And then in fourth place is the Espriu Foundation: the experience of ASISA, Assistència Sanitària and SCIAS, with an established position which has earned them international flagship status.
What prospects for health co-operatives have been opened up by the health care reform driven by President Barack Obama during his previous term as President of the USA?
Obama began by supporting the co-operative route in health care with his reform, although pressures served to limit this initial momentum. It would now seem that COOPs once again play a central role in Obama’s proposal. These are the ‘Consumer Operated and Oriented Plans’, inspired by the co-operative movement. They are medical insurers managed by the insured themselves, with a consumer-friendly approach. In the Anglo-Saxon world, in particular in the United States, co-operatives are essentially understood as user co-operatives. In the field of health, it would seem that professionals in the United States are not yet united enough for a co-operative approach to be considered. Nonetheless, the Espriu Foundation has had contact with a number of doctors in the country who are looking into the possibility of setting up professional co-operatives. Because our model demonstrates that the best approach is a two-fold application of the co-operative principle: co-operatives of medical professionals structured together with health user co-operatives, wherever possible. In the United States we are really held back by the social evidence that co-operatives need to be made up of users, evidence of which co-operative agents in the US are themselves aware. It’s a debate that has a lot of history: 150 years ago the Rochdale Pioneers tackled this problem of the borders between consumer and producer cooperativism. Within the International Co-operative Alliance, I have tirelessly emphasised the fact that you cannot have producer co-operatives without consumer co-operatives, and vice versa. These are the two variables of the co-operative equation, because otherwise the producers will always find themselves at the mercy of intermediaries. What co-operatives aim for is precisely to reduce the role of those intermediaries. The Espriu Cooperation model, involving producers and consumers, is undoubtedly the best solution, at least in the field of health.
What type of international relations do you share with health co-operatives?
It is important to avoid the concept of charity in international relations, whether North-South or horizontal. Our project is not simply about overseas aid, although it is a socially committed project which brings together different societies in the common pursuit of justice, as expressed through decent health care. Health Partners, the largest health co-operative in the world, undertook a project to develop the health co-operative movement in Tanzania. Having considered the results, they placed an emphasis on the returns which the project had generated: an analysis of what happened in Tanzania, allowing them to correct certain core elements of their process in the United States.
Do you believe that the Espriu model is suitable for the whole world?
If we analyse the health co-operatives belonging to the International Health Co-operative Organisation (IHCO), there can be no doubt about it. The only health cooperative model which does not strictly follow the principles of Dr Espriu might be the Japanese structure. And that is because of a cultural factor: one must always analyse the social context in which the model is rooted, as I mentioned earlier. In Brazil, though, for example, a country where co-operatives have played a hugely important social and economic role over recent years, every stage of the structure of the health co-operative movement is being built in accordance with the Espriu model.
What role would you predict for the health co-operative movement in Spain?
Spain has also experienced diversity, in that the model has evolved differently in Catalonia to the rest of Spain. The traditional tendency towards association membership in Catalan society allowed for the development of an attractive model, as in the Basque Country. The same tradition does not exist in other locations, except perhaps in Murcia, and so the Espriu model has developed in different ways. This diversity is also seen in the legal field, as we always refer to the Co-operatives Act without taking into consideration the differences in devolved regional legislation.
You need the perspective of history to understand the contribution of our co-operatives to Spanish society. We have always supported the National Government in matters of health care. Before Social Security existed as a developed model, the Espriu model was already in operation. The full development of the national health system, however, allowed us to play a new role. It should be remembered that the Spanish system was in its day copied from England. Well now in spring the Fundación Espriu will welcome a delegation from the English national health system which will analyse the mechanisms we use to implement our system, our current situation and the possibility of co-management between doctors and users. Because the British are being battered by the same economic storms as we are, and their renowned pragmatism prompts them to analyse all possible options in the quest for a solution. There can be no doubt that our option is a sound one.
Could we then consider the health co-operative movement as a general alternative, within the context of the economic crisis, at the Europe-wide level?
The task of the IHCO or our contact with the British system, or the exchanges which have been ongoing for more than a decade now with the Swedish health care system and throughout the world, all point in this same direction. Despite the bureaucratic problems which some co-operatives may have found in the International Co-operative Alliance, the Espriu Foundation has always been a reliable interlocutor in such cases. The structures need to be adapted according to each individual context: the most recent member we welcomed into the IHCO is a co-operative of workers in Poland, who asked us for flexibility in incorporating their internal functioning within international regulations.
What relationship do health co-operatives have with international bodies?
Through the ICA we are one of the advisory bodies of the UN, which, it should be remembered, played a fundamental role in declaring 2012 as International Year of Co-operatives, acknowledging the value of the influence which the co-operative movement has in civil society. And then there are organisations such as the ILO, UNAIDS, and in some circumstances the World Bank.
Right now we are re-addressing the relationship between the IHCO and the World Health Organisation (WHO), with which we have had an advisory role. At the most recent Executive Board Meeting of the IHCO we revisited the plans to maintain an official relationship with the WHO in order to perform very important lobbying work. As the WHO has up until now focused on support only for public health care, we are in a position to supplement this by analysing the role of the agents involved in health development and promotion: that is what we have been doing over recent years within the context of the Alliance for Health Promotion.
What values does the co-operative concept offer to WHO initiatives?
People have realised that the co-operative movement provides one of the most effective responses to the challenge of citizen involvement. Because we are a movement the fundamental basis of which is involvement by civil society in public health care efforts, presenting a valid alternative wherever necessary. Dr Eugenio Villar, the WHO coordinator on the Social Determinants of Health, has asserted that we need to establish new forms of collaboration. Not because the IHCO needs the WHO to develop, but in the interests of responsibility, in order to contribute towards global governance through our experience. Such dialogue could focus public policy and give us an important role as an international interlocutor for the IHCO and for the Espriu Foundation.
What has been the impact of the International Year of Co-operatives, proclaimed jointly by the UN and the ICA?
To begin with, it has given us greater visibility. But perhaps the most important aspect is the analysis and thorough reflection which we have undertaken within the International Co-operative Alliance. The main fruit of which has been the proposal to develop the Co-operative Decade, the blueprint for which was approved by the most recent ICA International Assembly in Manchester. This is a proposal based on five principles giving absolute priority to participation, without which there can be no co-operatives, and an interest in establishing consistent legal frameworks to guarantee the contribution and distribution of capital. The hallmark of our corporate identity is shared responsibility: in the administration of co-operatives, in ownership, in participation… It has also been an important year here in Spain. The CEPES (Spanish Social Economy Enterprise Confederation) persuaded the Spanish Congress of Deputies to sign up to International Year of Co-operatives, along with other organisations.
The International Year of Co-operatives coincided with the most difficult period of the economic crisis in the countries of Southern Europe. What lessons does it offer us?
We need to focus all issues, including economic ones, from the perspective of valuing and extending what we already have. I find it surprising that people talk of the co-operative movement as a new phenomenon, when the International Co-operative Alliance was founded in the late 19th century! And at the recent Manchester assembly we celebrated the one hundred and fiftieth anniversary of the Rochdale Pioneers. We need, then, to appeal to common sense: before looking elsewhere for the latest fashion or business trend, we need to look closer to home, to what we already have, to what has proven itself and demonstrated its effectiveness and fairness. I was very much struck by something Dr. Lopez, the IHCO member for Argentina, said: “We co-operatives are the daughters of all problems and the mothers of all solutions”. In 2007 we organised a seminar in Ostersund, Sweden, entitled Cooperation, Subcontracting and Public Procurement within Health Care and Welfare, which highlighted the fact that people always turn to co-operatives when faced with a high-cost problem which needs a more cost-effective solution. In our opinion this is an incorrect and incomplete approach and the wrong way of looking at things, because although we offer a good solution in such cases, we are even more effective in providing a fair distribution of profits in healthy economic situations so as to avoid excess cost and provide added benefits in resolving health issues, and added to this are the benefits resulting from the aforementioned participation of all agents involved, and the concept of joint responsibility.
Meanwhile, one should not mistake a pre-established model for any inflexibility in terms of application, or a lack of evolution, a luxury which no one can afford these days. We are under an obligation to explore all possible modifications, advances and new developments, all the more so given our awareness that the risk of so-called “demutualisation” is present worldwide. Because co-operatives, as they grow and develop, like any enterprise, above all in the social sphere, tend to forget their beginnings and transfer ownership to purely commercial companies, a factor that Dr. Espriu warned against twenty years ago.