Health Care Co-operatives Startup Guide Table of Contents

Transcription

1 Health Care Co-operatives Startup Guide Table of Contents Acknowledgments... 2 Introduction... 3 Objectives... 4 Section 1 Health and co-operatives in Canada Status of the health care sector in Canada Health and social services: Vision of the co-operative movement History of health care co-operatives in Canada... 8 Section 2 - The Co-operative Alternative in the Health Care Sector Identification of needs and co-operative solutions Comparative table of the features of the different types of undertaking Section 3 - Starting up a health care co-operative The seven phases in setting up a co-operative Business plan Available Resources Bibliography Book and Reference Section Research Reports Section Internet Section Other Section... 23

2 Acknowledgments This guide could not have been produced without the cooperation of many individuals and organizations. We would especially like to thank Berchmans Nijimbere. As part of an internship with the Conseil canadien de la coopération (CCC) in 1996 and a master s thesis in co-operatives management and development at the University of Sherbrooke, Mr. Nijimbere conducted research more comprehensive than our own on health care co-operatives in Canada. His paper served as a backdrop for this guide. We would like to express our gratitude for the invaluable contributions of all the resource persons, facilitators and participants involved in the various workshops on health care co-operatives that we have held as part of the annual CCC convention in recent years. They helped us affirm the role co-operatives must play in health care. We would also like to thank Jean-Pierre Girard, a researcher with the Guy-Bernier Chair in Co-operation. Mr. Girard wore many different hats during the project. He is chairman of the health care co-operative development subcommittee of the Conseil de la coopération du Québec. We would also like to thank all the members of that subcommittee, who agreed to share with us their vision of the health and social services sector. Lastly, we would like to thank all those who contributed directly or indirectly to the production of this guide. Health Care Co-operatives Startup Guide 2

3 Introduction This reference guide comprises three sections. The three sections can be used separately, because they are aimed at different audiences. However, we believe that all aspects of the development of health care co-operatives are covered in this guide. The first section is aimed at resource persons in the area of development, that is, people who work in the field with proponents of new co-operative projects. These resource persons have expert knowledge of the co-operative formula and its advantages and disadvantages, as well as the process of setting up a co-operative. However, it is quite likely that these people will have a limited knowledge of the health care sector or new facts related to health care co-operatives in Canada. Since this is still a new area, it is only natural that little be known about it. The first section therefore provides developmental resource persons with an introduction to the status of the health care sector against the backdrop of the Canada Health Act, social factors and the specific needs of Canada s Francophone and Acadian communities. We also suggest in this part approaches to development that are likely to generate interest among the people involved in creating new co-operatives in Canada. We then turn our attention to the co-operative movement s vision of health and social services. We present a history of health care co-operatives in Canada, which have grown rapidly even though the formula is relatively new. The second section is intended for both development resource persons and proponents of co-operative projects, be they communities interested in a consumers co-operative, individuals interested in a producers or workers co-operative, or multiple partners. We identify needs and different co-operative models. We also present a table comparing the different types of organization so that promotional groups can see the advantages and disadvantages of each and can make an informed decision as to which best meets their requirements. The third and final section is aimed primarily at those who have made the decision to move forward and start up a health care co-operative. To help them, we present the seven steps in the process of starting up a co-operative and the factors to be considered in drawing up a good business plan; a business plan is vital in arranging project financing. At the end of the section is a list of resources available within the co-operatives network. Health Care Co-operatives Startup Guide 3

4 Objectives The objectives of the guide are to: 1. serve as a basic reference tool for Canadians who wish to set up a health care co-operative in order to meet their health care and services needs; 2. serve as a means to mobilize Canadians and health care officials and make them aware of co-operatives as the best alternative amid the crisis in Canada's health care system; 3. serve as a tool for promoting health care co-operatives as organizations that would enable Canadians to take charge of the delivery of both short- and long term health care. This guide is also aimed at members of existing health care co-operatives, recipients of health care services, future creators of health care co-operatives, health care professionals and political officials. Section 1 Health and co-operatives in Canada 1.1 Status of the health care sector in Canada The Canada Health Act Passed by Parliament in 1984, the Canada Health Act ( the Act ) consolidates and modernizes the 1957 and 1966 statutes (Madore: 1993, 6). The Act states that in order to qualify for federal health care funds, the provinces must satisfy the five main criteria of the Canadian health care system. The five principles or standards of national health insurance are: 1. Universality: all residents of Canada must be entitled to public health insurance and insured services on uniform terms and conditions; 2. Accessibility: residents of Canada must have satisfactory access to medically necessary medical and hospital services without financial or other barriers, and physicians and hospitals must receive reasonable compensation; 3. Comprehensiveness: all medically necessary services provided by hospitals and medical practitioners must be insured; since the Act does not stipulate the quantity of services to be provided, the provincial governments have the option of defining which of those services will be insured services; 4. Portability: insurance must be maintained when a resident moves or travels within Canada or abroad (coverage of services rendered outside Canada is limited to services insured in the resident's province); 5. Public administration: the provincial health insurance plan must be administered on a non-profit basis by a public authority accountable to the provincial government for its financial operations (Health Canada: 1996). Created in the late 1950s, the Canadian health insurance plan guarantees Canadians equal access to health care regardless of their ability to pay. It provides protection for the majority of the Health Care Co-operatives Startup Guide 4

5 population, who otherwise might not be able to afford quality care. The health insurance plan covers insured health services, that is, health services which are medically necessary, and not extended health care services (Madore: 1993, 7-8). Insured health services include: 1. hospital services that are medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability, including accommodation and meals, medical and nursing services, drugs, and all medical and surgical equipment and supplies; 2. medically necessary services rendered by a physician; 3. medically necessary surgical-dental services that cannot be properly performed other than in a hospital. Extended health services include: 1. nursing home intermediate care service; 2. adult residential care service; 3. home care service and ambulatory health care service. These services may be subject to private, partial or full rates. They can vary considerably in scope, level of coverage and categories of beneficiary from province to province. Most Canadians seem to be happy with the plan, which has been very successful. It is highly regarded around the world and is the envy of many countries. None the less, the problems and abuse associated with the plan are partly to blame for the crisis our health care system is currently facing. Intrinsic in Canada's health care system is incentive for physicians to see patients and perform procedures needlessly (Foot: 1996, 213). As a result, the system is lacking in coordination of services, monitoring, management and control. All of the commissions of inquiry that have been set up to examine Canada's health care system agree that the problems are generated from within, not outside, health services systems. The commissions point to a number of causes. Systems management is centralized, bureaucratized and rigid and makes it difficult to ensure complementarity between institutions (Shah: 1995, 385). The poor management can be attributed to such factors as political opportunism, administrative carelessness, duplication and poor planning, integration and co-ordination coupled with abuse and misuse of resources by patients and physicians (Task Force on Values: 1997, 14) Social determinants of health The philosophy underlying Canada's health care system is based more on curative medicine than on the independence (empowerment) of the person and prevention: health care professionals focus on treating the illness rather than the causes. Health Care Co-operatives Startup Guide 5

6 The system advocates a patient-oriented approach: the care and services patients receive are not sufficiently integrated into their family, social, cultural and economic environment. There is considerably more emphasis on curative and hospital services than on preventive and ambulatory services (Shah: 1995, 385). A holistic approach must be considered in order to better understand and treat the patient; in other words, the patient should be viewed in his or her broad physical, biological and social setting, because there is a correlation between socio-economic factors and health. We now know that there are social, economic and cultural determinants of health, just as there are genetic determinants and determinants related to the delivery of health care (Task Force on Health Determinants: 1997, 6). The poorer and less educated a population is, the higher the incidence of health problems. The rise in unemployment and the decrease in transfer payments because of cuts in support programs (employment insurance and social assistance) play a big role in the deteriorating health of Canadians. Unemployment has a far-reaching and devastating impact on health when the social safety net fails (Task Force on Health Determinants: 1997, 13). Every national and provincial study underlines the need for a health strategy that addressed the determinants of health. All areas, with varying levels, are looking for models that effectively and economically address them. To rectify this situation, Canadians are beginning to understand that, if we are to positively affect health, national and provincial policies focusing on employment and economic growth should be added to the national health policy (public insurance). Economic standing has a considerable impact on psychological and emotional health and well-being. This means that a drop in the public's standard of living leads to a drop in the level of health. In these circumstances, which are the circumstances we are facing in Canada today, medical care is not enough to maintain and improve health. Canada spends more on health than most other developed countries but is still no healthier (Foot: 1996, 204). To make Canadians healthier, the Government of Canada should develop a real health-oriented policy that includes such variables as employment, education, higher salaries, family and communities New needs Many Francophone organizations in Canada have made health a priority issue for their community. After primary, secondary, college and even university education, the Francophone and Acadian communities feel it is important to control health care facilities or at least be able to obtain health care in their own language. All too often in many parts of Canada, Francophone senior citizens end up in distress because they cannot get the services they want in their mother tongue. At the same time, governments in many regions are hoping as never before to introduce new models for the delivery of heath care that are socially effective. One of those models is the co-operative. Some communities have started to take matters into their own hands. Some have set up health services committees to explore ways of obtaining health care and services in French. Others have decided to act immediately and have banded together to provide the services their community considers essential. Health Care Co-operatives Startup Guide 6

7 Take, for example, the small northern Ontario community of Noëlville. The Noëlville region was without basic health and long-term care services. There was no pharmacy. To obtain those services, people had to travel over roads that were treacherous, especially during the long winter months. The region also had problems with the stability and consistency of services. Many services had also been scaled back. Consequently, senior citizens losing their independence had to leave the region because there were no health and housing services, while young people were leaving the high-unemployment area for the regional hubs of Sudbury and North Bay. A form of community venture that would enable people to obtain quality health services and create stable jobs for youth therefore had to be promoted. The community, with a 65% Francophone population, wanted to set up a project that could help everyone, with any extra capacity being put to work for its members. The community also wanted to undertake a specially tailored initiative geared to its needs. Following discussions within the community, the co-operative formula was selected as a model for taking economic and community matters into hand. A group of about one hundred people duly established a co-operative through the Ontario government. Services will begin in In the current context of budget cuts, government withdrawal, hospital closings and the move toward ambulatory care, it is essential that new methods be identified in order to deliver health care services more effectively. In light of these environmental changes, new needs have arisen, and a number of specific plans to create health care co-operatives have been put forward in Canada. Because of population aging, the increase in the number of single people and the move toward ambulatory care, it is expected that more home care co-operatives and co-operative post-surgical care centres will be created. The experiment involving ambulance technicians in Quebec is certainly conclusive and may be extended to other regions of Canada. In rural areas, the shortage of health services also demands a co-operative solution that has to be promoted to local, regional and even provincial decision makers. The experiences of Noëlville, Ontario, and St.-Étienne-des-Grès, Quebec, should be widely disseminated so that people become aware of them. Consumer co-operatives in urban areas could be set up to bring together users interested in obtaining as a group services not covered by health insurance, such as alternative medicine services. Or, Co-operative Primary Health Centres could be formed to serve special needs groups such as women, seniors, aboriginal persons and those with disabilities. Finally, health care facilities in a given region could realize substantial savings by forming a procurement co-operative like the one that already exists in the Mauricie/Bois-Francs region of Quebec. Many other examples could be used to demonstrate the potential of the co-operative approach in health care. 1.2 Health and social services: Vision of the co-operative movement The Canadian co-operative movement felt it was important to adopt a vision of the organization of health care in Canada, a vision it hopes to share with as many people as possible. Understanding that vision is essential if one is to fully grasp the issues that come into play in creating health care co-operatives in Canada. Health Care Co-operatives Startup Guide 7

8 The Canadian co-operative movement: supports the findings of the National Forum on Health regarding the determinants of personal health; it believes that socio-economic determinants have an impact on health and the availability and quality of health services; holds the view that, in keeping with the many studies that have been conducted and in the name of the common good and collective interest, the government must retain central responsibility for regulating and funding health services; universal access to health care must not be called into question; holds the view that application of the co-operative formula in delivering health services must not be driven by market considerations, but must endeavour to meet the needs of users, with respect for and recognition of the contribution of health care professionals; views the creation of health care co-operatives as a way of responding to the wishes of the public and not as a way of questioning the relevance of the government's role in this area; health care co-operatives would give the public better access to and control over health services and would foster partnerships with public agencies; hopes to share with other social players its vision of the organization of the health care system. 1.3 History of health care co-operatives in Canada The idea of health care co-operatives is not new. In 1940, Jacques Tremblay, a young doctor in the working-class neighbourhood of St.-Sauveur in Quebec City, wrote many articles and gave many lectures on co-operative medicine. The Société St.-Jean Baptiste and the Ordre de Jacques-Cartier, in which he was a militant, gave him a forum through which to defend his ideas. The Coopérative de santé de Québec [Quebec City health care co-operative] was officially created on May 9, In June 1946, the co-operative extended its activities to the whole province and became Services de santé du Québec [Quebec health services]. It is now known as SSQ, Mutuelle d'assurance-groupe. Dr. Tremblay described co-operative medicine in a brochure published by the Conseil supérieur de la coopération (forerunner of the Conseil de la coopération du Québec), 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. While most provinces are only just beginning to experiment with health care co-operatives, Saskatchewan has been using the co-operative community clinics model since There are currently five health care co-operatives offering communities based medical, (which include day surgery, pharmacy, ophthalmology,etc.) rehabilitative and health promotion services to 17,000 members and 85,000 users in Saskatchewan. The first co-operatives were created in the wake of the crisis brought about by implementation of the universal health care system and the doctors' strike. It was during this period of turmoil that communities acquired the means to meet their own health care needs by setting up a network of co-operative clinics. The formula is characterized by the holistic approach to health care, Health Care Co-operatives Startup Guide 8

9 multitasking, prevention and user accountability. One basic feature of co-operative health care clinics is that all staff, physicians included, are paid a salary by the co-operative instead of being paid on a per-procedure basis. Many other co-operatives have since been created in the health care sector, particularly in the last ten years. Co-operative clinics have been established in Prince Edward Island, Quebec and Manitoba. In Quebec, a major workers' co-operative has been set up in the ambulance sector. Over the past two years, many home care co-operatives have been created, and a federation of home care co-operatives has been formed, with a major contribution from Assurance-vie Desjardins-Laurentienne. Ontario, too, is bustling with activity in the areas of health care, professional co-operatives, ambulance services, clinics, senior citizens housing that offers health care, hospital groups, etc. 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. Health Care Co-operatives Startup Guide 9

10 Section 2 - The Co-operative Alternative in the Health Care Sector 2.1 Identification of needs and co-operative solutions The changes governments have made in the delivery of health care services have put some rural communities at risk and created widespread insecurity among health care workers. The changes in provincial health care systems have given rise to needs and opportunities that are concerns for the co-operative sector in Canada. The co-operative formula may be a good way to improve the delivery of health care in your region. We therefore present four types of co-operative that may meet the wide range of needs related to health care services in your region. Consumers' or users' co-operative This type of co-operative is made up of users who band together to meet their health care needs and obtain adequate services or products. The model is particularly suitable for remote communities or communities that have been left without some services because of changes in the existing health care system or groups of people with special needs in urban setting. This model is also used to consolidate hospitals and other organizations in order to obtain volume discounts on purchases. Producers' co-operative This type of co-operative makes it possible to offer the best price for the goods and services it buys from its members. In the health care sector, for example, this type of co-operative can be used by groups of professionals to take advantage of affordable administrative services and perhaps even allow them to submit joint business proposals while at the same time guaranteeing maximum autonomy for the members. Workers' co-operative This type of co-operative is used to enable people to create their own jobs and secure better working conditions (pay, quality of life in the workplace, etc.) for the workers in the co-operative. This model has enabled many ambulance technicians, for example, to create their own democratic businesses that meet their very specific needs. Multi partner or solidarity co-operative The aim of this type of co-operative is to simultaneously meet the needs of different groups of members, such as employees and users. This model could play a key role in creating home care co-operatives. Health Care Co-operatives Startup Guide 10

11 2.2 Comparative table of the features of the different types of undertaking Co-operative Share corporation Non-profit organization Share of ownership A share does not carry a name. It is owned by the "bearer". The common share is registered in the member's name. The common share cannot appreciate. It cannot be bought other than by the co-operative, for the same amount as when the member joined. A member's liability is limited to the value of his or her common shares At general meetings, a member has only one vote, regardless of the number of common shares he or she owns. A common share can appreciate. A shareholder can sell his or her shares to another person at a mutually acceptable price. A shareholder's liability is limited to the value of his or her shares. Share of power At general meetings, a shareholder is entitled to as many votes as he or she has shares in the corporation. There is no ownership share. The members are accepted (or co-opted) as members when they agree to pay an annual fee that qualifies them as members. If they meet the membership criteria, any person can become a member, whether or not he or she uses or benefits from the services provided by the organization. One person, one vote. A member cannot vote by proxy or transfer his or her vote to a third party. Co-operatives legislation may limit or prohibit the payment of interest on the share capital. Some provincial statutes may stipulate that any or all of the co-operative's general reserve is indivisible. Surpluses can be paid into the reserve or to members in the form of discounts prorated to the member's dealings with the co-operative. A shareholder can obtain a proxy from other shareholders. Share of results There is no limit on dividends on shares. Shareholders can dispose of all of the corporation's assets subject to certain legislative provisions. Profits can be distributed in the form of dividends based on the rights established for the different classes of shares or reinvested in the corporation. Surpluses belong to the organization, not the members. This means they cannot be distributed to the members, but have to be paid into the organization's indivisible general reserve. From the Co-operatives Secretariat's information kit on co-operatives. Health Care Co-operatives Startup Guide 11

12 Section 3 - Starting up a health care co-operative This section of the document is aimed specifically at people who wish to form a group with common interests in order to create a health care co-operative. Creating a promotional group The first task is to put together a promotional team to analyse the various phases of the process of setting up a co-operative. It would be best at this point to join forces with people from different sectors.* For example, you could include people involved in health care, economic development, community leadership or the co-operative movement or representatives of senior citizens' and other groups. Any person who is motivated could play a very important role in this type of project. *The very important role of community leaders must not be underestimated when choosing associates 3.1 The seven phases in setting up a co-operative 1. Project design 2. Feasibility study 3. Viability study 4. Incorporation 5. Recruitment and training of members 6. Development of internal bylaws 7. Founding general meeting 1 - Project design Project design is the phase during which you have to put together a group to promote the project. The promotional group will have four tasks: 1.1 Set objectives 1.2 Identify resources 1.3 Gather ideas and make decisions 1.4 Determine work methods Set objectives The group has to set clear, quantifiable and realistic objectives relevant to the needs of the community. It has to begin by clearly identifying health care needs and taking stock of the resources already available within the community Health Care Co-operatives Startup Guide 12

13 1.2 - Identify resources During this phase, the group has to consider different scenarios for meeting the community's needs. It also has to be able to determine which interest groups support the project and which are opposed to it. Below is a partial list of organizations in which you might be able to find partners for a health care co-operative project. It should also be made clear that the co-operative formula may not be the best way to meet the community's needs. In this regard, the promotional group should also gather information to learn more about other types of organization. Organizations likely to provide assistance: provincial co-operation councils; regional development co-operatives; your local credit union or another financial institution; co-operatives in other sectors (agriculture, housing, consumer action, services); senior citizens' groups; economic development associations or corporations; municipal councils; cultural associations; foundations operating in Canada; and of course your friends, relatives and colleagues Gather ideas and make decisions At the end of this phase, the group has to compile the pertinent information, decide where to go next and choose the project structure. If the group decides to carry on with the project, it has to gather more detailed information by conducting feasibility and viability studies Determine work methods If the group decides to proceed, we suggest that you select work methods that are adequate and effective considering the members of the group. Timetable and work plan For example, you should draw up a timetable for your work plan. The timetable should include deadlines for the different tasks and the dates and times of upcoming meetings. Health Care Co-operatives Startup Guide 13

14 Meetings There are many books on conducting effective meetings. We urge you to consult several. Distribution of tasks To make the process more effective, you could split up some tasks, such as funding, recruitment of members and internal bylaws. The people handling each area would have to share the results of subgroup meetings at meetings of the promotional group and report on their progress. 2 - Feasibility study What is a feasibility study? The purpose of a feasibility study is to determine whether a project can be done. It examines elements that will indicate that the project should proceed if the results are positive or abandoned if the results are inconclusive.* The purpose of this section is not to answer all the questions, but to raise points that will have to be expanded on in the next phases of your project. *(Definition from a document produced by the Quebec federation of school co-operatives entitled La création d'une coopérative en milieu scolaire en 8 étapes [creating a school co-operative in eight steps], p. 5) 1. What do you want to do and why do you want to do it? How did your initiative come about? What needs does your co-operative address? What are the objectives of the co-operative in terms of adequately meeting the needs of its future members? What are the objectives of the corporation in terms of adequately meeting the needs of its future clientele? 2. What are your technical qualifications in management and co-operation? Draw up a profile of the promotional group that wants to create this co-operative. 3. What technical resources are available within your community? Determine the skills needed to start up your co-operative or corporation. Identify the people likely to provide you with those skills. 4. What is the status of the co-operative sector or business sector in the region where you want to set up operations? What are the main problems and major successes? Health Care Co-operatives Startup Guide 14

15 Is the sector growing? Stable? Declining? Who are your competitors? Direct and indirect? 5. What are the different scenarios or options that could be used to carry out this co-operative or corporate project? Scenario 1 Strengths: Weaknesses: Scenario 2 Strengths: Weaknesses: Choose the best scenario and give reasons for your choice. 6. What is your project? Briefly describe your project based on the scenario you chose: Identify the planned activities (services, activities, goods, etc.) Identify the technical and human resources needed to meet the established objectives. 7. What is the total cost of the project? 8. How will you finance this co-operative or corporation? 9. What are the objectives in terms of members and employees? Number: Who: 10. Socio-economic features of the surrounding community: What do you know about the community? How many active co-operatives are there in the region, and in what sectors do they operate? 11. What co-operative or community organizations would be willing to support you in creating this co-operative or corporation? How? 12 Based on this exercise, what is your assessment of the project? 13 Is the project feasible? If yes, why? If not, why not? Health Care Co-operatives Startup Guide 15

16 3 - Viability study If the results of your feasibility study are positive, the next step is to draw up an operating budget and a financing plan to show that the project is practicable. The first thing you will have to do is take stock of your basic internal and external financing. You will then have to determine the operating costs of the co-operative and project potential revenue. (Section Business Plan section) Financing a Co-operative This is a crucial phase of the project. You have to determine how your co-operative project is going to be financed. There are several ways to approach the financing of a health care co-operative. 1. Members' common shares The first element is the share capital compiled by selling partnerships to the members of the co-operative. This money will be used as the corporation's capital and can often be helpful in finding other investors. Common shares guarantee voting rights within the co-operative. 2. Preferred shares Preferred shares are financial investments in the co-operative undertaking. Some people in your community may express an interest in investing in a health care co-operative. Preferred shares can pay the investor interest and enable the co-operative to obtain stable financing, usually at a competitive rate. It is also possible for organizations to become involved financially. Where the co-operative is stakeholder in community health, the municipality, the credit union or community groups may decide to support you by buying preferred shares. It is interesting to know that preferred-share investments may qualify for a registered retirement savings plan (RRSP) and generate a tax deduction for the investor. Preferred shares therefore help ensure a stronger capital base for the co-operative and at the same time create tax deductions for investors. Preferred shares do not guarantee the investor the right to vote. However, the co-operative is bound to consult preferred shareholders from time to time. You must check the provincial legislation for more information. 3. Gifts and grant programs You may receive gifts or grants to maintain or improve health services. Your co-operative may be eligible for government or other grants. 4. Loans At this point, you will have to present your business plan to the various financial institutions in your area in order to negotiate an agreement for the start-up and operation of your co-operative. Health Care Co-operatives Startup Guide 16

17 It is essential that you know your project inside out so that you can win the confidence of your financial institution. General criteria used by financial institutions in making loans. Your financial institution will consider the following elements before deciding whether to finance your project: (This list of criteria was verified by management of the Caisse populaire d'orléans) 1. Ability to repay Based on your realistic budget projects, are you able to pay your debts? 2. Management capability Do your work team and board of directors have expertise in health services and business management? 3. Ability to reinvest What are the prospects for reinvesting funds in the project in the event of growth or difficulty? Do you have the support of reliable organizations? 4. Knowledge of the field Have you attracted people with experience in health services who can help you avoid making mistakes? 5. Type of project What are the prospects in your area of activity in terms of health care and home care services? 6. Financing What are your financing methods? (mortgage, business loan, etc.) 7. Guarantees What guarantees are in place in case of financial difficulties? 4 - Incorporation You will have to obtain a copy of your provincial legislation on co-operatives or the federal statute as needed. Because legislation is complex and sometimes abstract, we recommend that you first become familiar with the guides produced by co-operative development organizations in order to help you understand the co-operative formula. You could also get information on other forms of incorporation so that you can choose the right structure for your needs. It should also be noted that co-operatives legislation generally allows different types of co-operative to be created. First, you can establish a co-operative with share capital. This allows you to issue common shares and preferred shares. Second, you can opt for a co-operative with no share capital. This type of co-operative can be recognized as a non-profit organization and registered as a charitable organization. Any person who makes a donation to an organization with a valid registration number is entitled to a tax deduction. Finally, it is important to clearly define the needs and determine which formula is most suitable. Health Care Co-operatives Startup Guide 17

18 5 - Recruitment and training of members Co-operatives training To ensure that the co-operative continues to pursue the objectives set at the time it was founded, it is essential that the members of the organization make new members aware of the principles of co-operation through a range of interesting activities. It may be very useful to provide staff education in co-operative values, organization and practices. Training Because your organization is geared toward health, it would be interesting to give some thought to organizing training workshops on prevention in order to improve the health of members and the community. Recruiting Members Finally, during this phase, you will also have to analyse your techniques for recruiting new members. Do you plan to use the media or hold information sessions? It is crucial that you develop recruitment and marketing strategies for your co-operative. It is also essential that you draw up a membership policy. How much will people have to pay to become a member of the co-operative? Will you accept auxiliary members?* What terms of payment will apply? It would be preferable to allow members to pay for their common share in instalments the first year. The goal of a co-operative is not to make things hard for the disadvantaged, but to serve those who wish to become members. *A co-operative could define a territory to form its membership base and offer auxiliary memberships to residents outside the established boundaries. 6 - Development of internal bylaws Internal bylaws include resolutions passed by the members in a general meeting. The bylaws must set out the methods and procedures needed to ensure that your co-operative works smoothly. Health Care Co-operatives Startup Guide 18

19 There is no need to reinvent the wheel! Before drafting the internal bylaws, you could obtain samples to be used as a backdrop. The following are the main points covered in internal bylaws: key definitions address of the head office corporation name and seal description of share capital rights and privileges of members procedures during meetings of members composition and election of board of directors proceedings of the management committee or executive committee description of the roles of the members of the executive committee dates of fiscal year allocation of surpluses and dividends borrowing power co-operative auditor signatories dissolution clauses special provisions language of co-operative management procedures for amending the internal bylaws. 7 - Founding general meeting Finally, at the founding general meeting of the co-operative, the members have to perform four very specific tasks: 1. pass the internal bylaws prepared by the promotional group; 2. elect the board of directors; directors are chosen from among the members of the co-operative and have a mandate to ensure that the policy directions set by the members in a general meeting are followed; the members also have to hire a person for the position of executive director or manager; that person is usually required to have good accounting and personnel management skills and knowledge of the co-operatives sector; 3. issue common shares in accordance with the co-operative bylaws; 4. appoint a firm or individual as the co-operative's auditor; that person must be a chartered accountant. 3.2 Business plan (This part of the guide is based on the following document: Morin Chantal, Les étapes pour bien structurer un projet et partir son entreprise [keys to devising a plan and starting a business], Quebec Department of Industry, Commerce, Science and Technology, Mauricie/Bois-Francs Branch, March 1994, 35 p.) This section of the guide comments on the development of a business plan and the project itself. Health Care Co-operatives Startup Guide 19

20 Developing a business plan: 1. Consult your financial institution for pertinent and helpful information on their requirements. 2. Prepare a draft business plan using the procedure set out in this guide and filling in the following five-part fillable PDF form [PDF Help]: 1. The project 2. Promotional Group 3. Marketing 4. Operation 5. Financial projections 3. Stay in close contact with your financial institution regarding the progress of your project. 4. Familiarize yourself with this section and then share your ideas with the rest of the group. 3.3 Available Resources CCA Regional Offices and Affiliates: Community Health Co-operative Federation of Saskatchewan 455-2nd Ave N Saskatoon, Saskatchewan S7K 2C2 Telephone: (306) Fax: (306) CCA Ontario 415 Yonge Street, Suite 601 Toronto, Ontario M5B 2E7 Telephone: (416) Fax: (416) info@CoopsCanada.coop Regional Co-operative Development Centre 36 Albert Street Moncton, New Brunswick E1C1A9 Telephone: (506) Fax: (506) rcdc@nbnet.nb.ca Manitoba Cooperative Council 177 Lombard Avenue, Suite 801 Winnipeg, Manitoba R3B 0W5 Telephone: (204) Fax: (204) cvillega@mts.net Rural Education and Development Association (REDA) , 172nd Street Edmonton, Alberta T5S 1K9 Telephone: (403) Fax: (403) ruraled@compusmart.ab.ca CCA Saskatchewan 333-3rd Avenue North, Suite 501 Saskatoon, Saskatchewan S7K 2H9 Telephone: (306) Fax: (306) ccasask@webster.sk.ca Health Care Co-operatives Startup Guide 20

21 CCA British Columbia West Hastings Street Box Vancouver, British Columbia V6B 4N5 Telephone: (604) Fax: (604) Francophone Provincial Co-operative Associations: Conseil de la Coopération de l'ile-du- Prince-Édouard Wellington, Prince Edward Island C0B 2E0 Telephone: (902) Fax: (902) Conseil Albertain de la Coopération th ave. SW Calgary, Alberta T2T 2T8 Telephone: (403) Fax: (403) Conseil de la Coopération de l'ontario 450, rue Rideau, Bureau 203 Ottawa, Ontario K1N 5Z4 Telephone: (613) Fax: (613) Conseil Coopératif Acadien de la Nouvelle-Écosse Case postale 667 Chéticamp, Nova Scotia B0E 1H0 Telephone: (902) Fax: (902) Fédération des coopératives de services à domicile du Québec 150, ave. des Commandeurs Lévis, Québec G6V 7N5 Telephone: (418) or Fax: (418) Conseil de la Coopération du Québec 4950, boul. de la Rive Sud, local 304 Lévis, Québec G6V 4Z6 Telephone: (418) Fax: (418) Conseil Acadien de la Coopération 295, boul. St-Pierre ouest, C.P Caraquet, New Brunswick E1W 1B7 Telephone: (506) Fax: (506) Fédération des coopératives de développement régional du Québec 2095, rue Jean-Talon Sud, bureau 226 Ste-Foy, Québec G1N 4L8 Telephone: (418) Fax: (418) Conseil de la Coopération du Manitoba 605, rue des Meurons, bureau 100 St-Boniface, Manitoba R2H 3B4 Telephone: (204) Fax: (204) Conseil de la Coopération de la Saskatchewan , Hillsdale Street Regina, Saskatchewan S4S 7J5 Telephone: (306) Fax: (306) Health Care Co-operatives Startup Guide 21

22 Bibliography Book and Reference Section Angus, E. Douglas; Manga, Pran. Efficacité des modèles de prestation coopératif /communautaires des soins de santé, CCA-CCC, Ottawa, août 1990, 85 p. College of nurses of Ontario. Standards of nursing practice, Toronto, 1990, 43 p. Conseil de la coopération de l'ontario. Guide pour la création d'une coopérative, Ottawa, avril 1986, 32 p. Ministère de la Santé de l'ontario. Exigences provinciales concernant le processus de la demande de propositions pour la prestation de services, de fournitures et d'équipement à domicile, Toronto, mai 1996, 68p. Ministère des Finances, services de développement des coopératives. Les coopératives en Ontario : Comment constituer une coopérative, Ontario, juin 1995, 42 p. Ministère des Finances, services de développement des coopératives. Les coopératives en Ontario : Exigences légales, Ontario, juin 1995, 44 p. Ministère des Finances, Exigences en matière de dépôt de dossiers, Ontario, juin, 1995, 12p. Mosby's Dictionnary. Medical, nursing and allied health, Mosby, St-Louis, 1990, 1608 p. O'Shaughnessy, Wilson. La faisabilité de projet, une démarche vers l'efficience et l'efficacité, Les éditions SMG, Trois-Rivières, 1992, 214 p. Ouellet, Line; Vallières, Marc. SSQ Mutuelle d'assurance groupe L'Histoire d'un succès collectif. 147 p. Primary health care of the provincial co-ordinating commitee on community and academic health science centre relations. New directions in primary health care, Toronto, July 1996, 57p. Rice, Robyn. Home health nursing practice, Mosby, St-Louis, 1996, 489p. Secrétariat aux coopératives. Histoires à succès des coopératives, Gouvernement du Canada, Ottawa, décembre 1995, 54 p. Secrétariat aux coopératives. Trousse d'information sur les coopératives, Gouvernement du Canada, Ottawa, 1999, 36 p. Tchobroutsky, Georges; Wong, Olivier. La santé, Paris, PUF, 1995, 108p. Health Care Co-operatives Startup Guide 22

23 Research Reports Section Boissinot, Michèle. Travail en économie de la coopération «La coopérative de services à domicile de l'estrie», Université de Sherbrooke,1995, 37p. Boissinot, Michèle; Garon, Isabelle. Guide de démarrage pour les coopératives de services de santé Collection Essais # 27, IRECUS, Sherbrooke, 71 p. Comeau, Yvan; Bourque, Raymonde; Vaillancourt, Yves. Cahier de recherche «Auxi-plus : Monographie de l'agence coopérative d'auxiliaires familiales de Montréal», Chaire de Coopération Guy-Bernier, UQAM, Montréal, 1995, 44p. Côté, Daniel; Grenier, André; Juneau, François; Nijimbere, Berchmans; Zabo, Ndavo ; Girard, Jean-Pierre (supervision). Rapport préparé pour le secrétariat aux coopératives du Canada «Le développement des cliniques coopératives de santé en Saskatchewan», Université de Sherbrooke, IRECUS, juin 1996, 39 p. Comeau,Yvan; Girard, Jean-Pierre. Cahier de recherches, «Les coopératives de santé dans le monde, une pratique préventive et éducative de la santé», Chaire de Coopération Guy-Bernier, UQAM, Montréal, 1995, 138 p. Girard, Jean-Pierre. «Les coopératives de santé et le contexte canadien en 1996 : quelques éléments de réflexion», UQAM, Chaire de Coopération Guy-Bernier, Montréal, 1996, 44 p. (texte non publié) Nijimbere, Berchmans. Guide d'implantation d'une coopérative oeuvrant dans le domaine de la santé. Essai présenté pour la maîtrise en gestion et développement des coopératives, IRECUS, Sherbrooke, 1997, 144 p. Vaillancourt, Yves. «Comment poser le problème de la privatisation dans le réseau de la santé et des services sociaux au Québec», UQAM, mars, 1996, 57p. (Texte préparé pour présentation ultérieure) Internet Section Association of Ontario Health Centres Canadian Medical Association International Co-operative Alliance Para-Medical Services Inc. Other Section CCA Ontario. Health Care Co-operatives, Toronto, 7p. Health Care Co-operatives Startup Guide 23

24 Coopérative de développement régional, région de Québec. Document d'information marketing. Conseil de la coopération de l'ontario; Juneau, François. Le développement des coopératives de santé : La coopération une idée saine. Ottawa, 1997, 72 p. Conseil de la coopération du Québec. Coopératives de services à domicile : Une avenue prometteuse pour répondre aux besoins des aînés, Lévis, novembre 1995, 5p. Conseil de la coopération du Québec. Guide de démarrage : coopératives de services à domicile, Lévis, février 1996, 12 p. Direction des coopératives. Guide pour la préparation d'un projet de coopérative, Gouvernement du Québec, Québec, août, 1984, 12 p. Drouin, Line; Morin, Chantal. Les étapes pour bien structurer un projet et partir son entreprise, ministère de l'industrie, du Commerce et de la Technologie du Québec, Direction régionale Mauricie/Bois-Francs, mars 1994, 35p. Grenier, André; Juneau, François; Nijimbere, Berchmans. Les coopératives de la Saskatchewan : Un modèle à suivre? Réseau Coop, vol 3 # 5, 1996, p.10 Loi sur les sociétés coopératives de l'ontario, Toronto, Imprimeur de la Reine pour l'ontario, mai 1993, 120p. Ontario Worker Co-op Federation. Business Plan Workbook, Ontario, 26 p. Sous-comité du développement coopératif dans le domaine de la santé. La vision du système de la santé et des services sociaux. Québec, 1997 Health Care Co-operatives Startup Guide 24