«Co-operatives are the public sector’s greatest allies in the field of health»

Interview with Giuseppe Milanese, President of FederazioneSanità – Confcooperative, the apex organisation of health co-operatives in Italy.

What is the origin of FederazioneSanità and what are their activities and future projects?
FederazioneSanità was founded in 2010, in order to inte­grate the different co-operative primary care players and to overcome the competition and segregation among pro­fessional experts. Nowadays we about 380 coops are asso­ciated: co-operatives of physicians, pharmaceutical coops, co-operatives specialised in healthcare and social-health mutual entities. Our core activity is the promotion, the support and the planning of multi-professional and inte­grated co-operative local networks, gathering social and healthcare services according to a logic of synergy and mutual support. At present, we are working to build together with the other federations of Confcooper­ative a co-operative welfare system. The aim is to submit a pillar founded on mutualism to the Italian Government, for a renewal of the Italian welfare system, trough new public-private partnership models.

Giuseppe Milanese

What is the level of implementation of the health co-operatives in Italy?
Since the ’80s in Italy, the coops have guaranteed assistance to the citizens in their home or in territorial facilities. Ac­cording to our data, the Italian co-operative movement serves 7 million citizens in the field of social and health care. Our coops work in many sectors: assistance to frail people (elderly, disabled persons, alcohol or drug addicts, etc.); homecare, nursing and rehabilitation services; as­sistance in the areas of mental disorders and rare genetic diseases; without forgetting the pharmaceutical coops and the cooperatives of physicians. This has been possible be­cause Italian co-operation has a broad and structured legal framework: Article 45 of the Italian Constitution recogniz­es and promotes co-operation and its social function; our Civil Code includes a section entirely dedicated to co-op­erative businesses; in 1991, Law no. 381 established a new specific typology, the “social co-operative” with the core mission of providing health and social services to the citi­zens. In addition to this, co-operation has been regulated by other specific laws, such as the Legislative Decree no. 1577/1947 and the Legislative Decree no. 220/2002 which both give a primary role in the administrative audit on coops to representative associations like Confcoopera­tive; or Law no. 59/1992 and Law no. 142/2001 which both regulate the role of working members. In addition, the Italian Parliament is currently studying a new reform of the Non-profit entities in order to modernize the social economy sector. Finally, it is important to highlight that at the administrative level the Italian Ministry of Labour has a General Directorate dedicated to co-operation.

How does the collaboration between the public health system and health cooperatives work in Italy?
In Italy, the milestone for the collaboration with the public system has been the Law no. 381/1991, which recognizes the coops working in the area of social and healthcare services as entities able to pursue the general interest of the community, the human promotion and the social in­tegration of citizens. But in these years the co-operative model has qualified itself as an appropriate tool to manage the public-private collaboration in several areas of prima­ry care. In the medical sector, according to the National Collective Agreement of the general practitioners, the co-operatives are being recognized as aggregating tools of physicians. In the pharmaceutical area, instead, the coops can be owners of pharmacies (maximum 4 phar­macies, but this situation will undergo a reform soon). Nowadays, according to Law no.183/2011 there are new opportunities for growth of professional cooperatives in healthcare, because this law removes the prohibition of founding companies among professionals. In relation to demand, Italian law gives mutual entities the oppor­tunity of providing healthcare and social assistance or cover the costs with healthcare plans, as well as through the management of supplementary funds. So, from the point of view of the public-cooperatives relationship, In Italy this collaboration has existed since many years, but we are working for a new development on this issue. So far the public-private relationships were managed most­ly through public tenders. This tool is characterized by discontinuity in the services, a low level of innovation, no freedom of choice for the patients and less attention to quality of assistance especially in the system of “largest discount tenders”. For these reasons, public tenders are not adequate to manage these delicate partnerships. So we are striving to extend the “accreditation system” to providers of primary care, because in Italy it is restricted just to the hospital sector. We think that the accreditation ensures continuous improvement and innovation by pro­viders, freedom of choice by the customers, high quality services, continuous monitoring by the Public Adminis­tration on the basis of health outcomes. This is the only way for a new and strong development of public-private partnership in our country.

Do you believe that health co-operatives provide a gen­uine alternative for development of national health sys­tems? Why?
The healthcare coops can be the best partners for the Public Administration in the healthcare field. First, be­cause the co-operation is founded on values (solidarity, equity, mutualism, etc.), for this reason it can ensure both the proper economic management and high-quality ser­vices available even for low-income citizens. Moreover co-operatives and mutual entities that are democratic and open to free membership are the “key-instrument” for the full involvement of citizens in the active defense of health and in controlling related services. Without forget­ting that the coops, with specific characteristics in the dif­ferent countries, have developed know how, professional skills, innovative models, which have gained the citizens’ trust. Nevertheless we believe that to become a real pillar of a new welfare, the co-operatives must be organized in a system.

FederazioneSanità recently joined the International Health Co-operative Organisation, what do you think are the challenges of the international cooperative movement in the health sector?
Healthcare co-operatives are born to respond with facts (services and assistance) to people’s needs. It is still their challenge, mainly in the primary care field. The inter­national movement has the task of continuously giving prominence to co-operation, as a structured, sustainable and effective model to response to the needs mostly out of hospital: in the low-income countries, where it is neces­sary to provide basic services; in the middle-income coun­tries, in which the “new” chronic diseases are growing while the “old” epidemic diseases remain; in the high-in­come countries, where the economic crisis has left the poorest part of population without assistance. Last Octo­ber, during the International conference on “Feeding the welfare. Co-operatives in health care” held in Milam it was reported that 87 million people receive assistance from co-operatives. The healthcare co-operation is already ex­ceedingly active, but this is not common knowledge. As an international co-operative movement we must achieve the objectives of Alma Ata Declaration, reaffirmed after thirty years in the “World Health Report 2008: Primary Health Care – now more than ever”. The relevance of primary care is also proved by the growing interest of multinational corporations, for example the Gates Foun­dation and some big players from Silicon Valley. We don’t believe in primary care managed in a capitalistic way, but through a model founded on values and principles like those offered by co-operation. For these reasons we must strive so that our role and efforts be widely recognized.

The Blueprint for a Co-operative Decade, launched by International Co-operative Alliance, aims that co-opera­tives become the preferred business model in 2020. What initiatives are developing the Italian co-operatives related with the Blueprint?
The Blueprint strategy, to reach the targets of the plan “2020 Vision”, identifies five “key-issues”: participation, sustainability, identity, legal framework and capital. Fed­erazioneSanità and Confcooperative are working on each of these. We aim at building a co-operative welfare system inspired by the principles of quality, economic sustaina­bility and at co-operative values. We believe in the “wel­fare community” model and we are working in order that our more advanced coops open their social structures to the patients, as a new frontier of participation and con­trol also from the bottom. As for as the legal framework, Confcooperative follows carefully the draft reform on non-profit entities under discussion in the Italian Parlia­ment. With the reform the Government wants to promote growth, employment and the development of activities in the field economy sector. Moreover, Confcooperative and FederazioneSanità are working to support the coops merging together (especially in the pharmaceutical sec­tor) to create larger business entities able to attract funds by big investors. This is the only way to compete in the new open market in Italy and in Europe.

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