Cooperatives in Healthcare: Unimed do Brasil and P4P

June 25, 2012 § Leave a comment

Cooperatives in HealthcareCooperatives in Healthcare: Unimed do Brasil and P4P

At the height of the debate on American health care reforms, the primary issue revolves around how to lower the cost of healthcare services.  Yet, from a cost-and-benefit viewpoint, lowering the cost and price of healthcare may prove problematic as it may inadvertently decrease the quality of service delivery.  When hospitals, doctors or insurers receive less remuneration than what they previously received, they may, as rational agents, exercise lesser effort and commitment in return.

In the ensuing debate, cooperatives emerged as a key strategy for keeping healthcare costs and insurance premiums affordable.  Cooperatives are able to control the high cost of prescription medicines, help community-owned hospitals remain independent, and improve the quality of healthcare and assisted living.[1]  While there were doubts on the extent on the capabilities of cooperatives, there are already successful cases of healthcare cooperatives that deliver affordable prices and maintain quality delivery in other parts of the world.

Cooperatives have long been at the forefront of the Brazilian health care system.  Serving since 1967, Unimed do Brasil is the biggest private healthcare operator in Braziland has the largest network of medical cooperatives in the world.  The entire system consists of 370 medical cooperatives, 109,000 doctors and 3,029 accredited hospitals, providing care to more than 18 million customers.  It currently covers more than a third of the Brazilian market for health plans.[2]

True to the cooperative values, Unimed launched its National Policy on Social Responsibility in 2001, with the aim of practicing social responsibility in managing business.  In line with this mission, cooperatives in the Unimed network have undertaken initiatives to improve health care delivery; one of which, is the pay-for-performance (P4P) scheme which has been piloted by cooperatives like Unimed-Franca and Unimed-Belo Horizonte.

The P4P scheme rewards healthcare providers with financial incentives in meeting certain quality or efficiency targets.  The scheme may also include disincentives for poor performance where hospitals, for instance, are fined for failing to meet reduction targets or physicians are not reimbursed for the cost of treating medical errors.  The OECD acknowledges the potential of P4P scheme to go beyond mere encouragement and actually improve the quality of health care.[3]  While there is yet no clear evidence of the effectiveness of the scheme, pay-for-performance has steadily becoming popular in both private healthcare providers and cooperatives in countries including the United States, United Kingdom, New Zealand, Australia and Korea.

Unimed-Franca implemented its FFS+P4P (fee-for-service + payment-for-performance) in 2009.  Its aim is to control costs and improve doctor’s remuneration while still ensuring the quality of healthcare delivery.  The scheme rewards doctors depending on how they compare to their colleagues, looking into performance domain such as utilization, cost, effectiveness, healthcare and patient satisfaction.[4]  While there are no set absolute targets, there is a benchmark interval scoring, based on the average performance of all doctors.  Meeting the scores result in a percentage increases in consultation fees, which are shouldered by Unimed Franca.

On the other hand, Unimed-Belo Horizonte’s (UBH) program catered to both hospitals and doctors.  A hospital accreditation program, known as the Service Network Qualification Project, was instituted in 2004, aiming to standardize the provision of quality care among hospitals in the city of Belo Horizonte.  Together with the Diagnosis-Related Group (DRG) method, these allow comparison of performance across hospitals.  Hospitals receive an increase in per diem rate in joining and meeting targets in the accreditation process.  Accredited hospitals accounted for 65 percent of all UBH hospital admissions in 2008.[5]  Among doctors, UBH rolled out the pay-for-chronic disease management that tries to improve compliance with clinical guidelines and reduce avoidable hospitalization for cases such as diabetes, asthma, gyncaecology, etc.  Similarly, financial incentives are rewarded for good performance.

Rewarding incentives for good performance sounds like common sense.  Yet, the evidences of success with P4P schemes are inconclusive.  While the experience of Unimed-Franca has been promising, with patient satisfaction and preventive care increasing and average per consultation cost decreasing, Neves de Faria points out that many other health measures have little improved and that a time trend might be influencing the decrease in average cost.  Consequently, she concluded that it is unclear whether the program has a meaningful impact on performance.

As for UBH, Borem, et. al. highlight many positive impacts such as the improved health status of clients enrolled in the P4P program, citing that hospital admission among asthma patients dropped significantly.  Moreover, because of lower number of hospitalizations, the total cost to treat patients enrolled in P4P program dropped from US$ 90,000 to US$ 75,000.  Yet, they also find that the amount of incentives generates different results for different programs and they had to advise early on, that it is necessary to clearly distinguish P4P from other initiatives that increase provider remuneration.  Lastly, it should be considered that there are significant costs associated with both the collection of data and the increased financial incentives.

P4P schemes are attractive because at the core of the program is the attempt to put people first through the quality of health service delivery.  This nature suits well the very values for which cooperatives thrive.  Yet, like any program, there is a need for sufficient and reliable evaluation to measure its impact and sustainability for cooperatives must be mindful that for then to be successful, they still have to make profits.  In time, newer evaluation designs may arise to understand the true impact of P4P.


[1] NCBA website.  Available [Online]: < http://www.ncba.coop/ncba/about-co-ops/co-op-sectors/146-healthcare> May 21, 2012.

[2] Unimed do Brasil Website.  Available [Online]: < http://www.unimed.com.br/pct/index.jsp?cd_canal=49146&cd_secao=49094> May 16, 2012.

[3] OECD, “Improving Value in Health Care: Measuring Quality” OECD Health Ministerial Meeting Forum on Quality of Care, October 2010, p. 5.

[4] Rita Isabel Neves de Faria, “Pay-for-Performance inBrazil”University ofYork, September 2010, p. 25.

[5] Paulo Borem, et al., “Pay-for-Performance inBrazil: Unimed-Belo Horizonte Physician Cooperative,” Health System 20/20 P4P Case Studies, USAID, 2010.

Cooperatives and Women: Promoting Self-Empowerment

April 18, 2012 § Leave a comment

Cooperatives and Women

“Cooperatives, and other collective forms of economic and social enterprise, have shown themselves as distinctly beneficial to improving women’s social and economic capacities.”

Women around the world contribute to their societies in many different ways. Quite often these contributions are not fully recognised and appreciated.

On 8 March each year the international community commemorates the International Day of Women, not only as a means of lauding some of these unrecognized and underappreciated contributions, but also to reflect on those areas of continued systemic discrimination against women and inhibition of their capacities.This past International Women’s Day, the world stopped to reflect on the plight of women in rural areas, and their unrealized potential for ending the global maladies of poverty and hunger.

The limitations and discrimination facing women as farmers and agricultural producers have profound effects, not just on the women affected, but also on society as a whole. In the State of Food and Agriculture Report 2010-11, the Food and Agriculture Organization of the United Nations suggested that increasing women farmers’ access to and use of productive resources could increase total agricultural output in the developing world by 2.5 to 4 per cent, potentially reducing hunger by 12-17 per cent.[1]In this context, cooperatives, and other collective forms of economic and social enterprise, have shown themselves as distinctly beneficial to improving women’s social and economic capacities.

The benefits to women of cooperative organization

In a study on women producers and the benefits of collective forms of enterprise, Jones, Smith and Wills found that organizing into collective enterprises, such as cooperatives, enables women to unite in solidarity and provide a network of mutual support to overcome restrictions to pursuing commercial or economic activities.[2]Similarly case studies of women’s cooperatives in rural Nigeria and rural India indicated that, compared to non-cooperative members, women engaged in cooperative activities were better off, in terms of productivity and economic wellbeing.[3],[4]In the Indian study, the members of the cooperatives reported on their increased economic security, the entrepreneurial skills acquired, and their increased contributions to the economic wellbeing of their families.[5] 

Through cooperative organization, women have also been able to effect positive change in thesocial and physical wellbeingof their families, communities, and nation. For instance, The Uganda Private Midwives Association helps change the daily lives of its members and the wider community by addressing maternal and infant care.[6]Similarly, the Kilimanjaro Native Cooperative Union has developed some innovative programmes focused onaddressing the needs of children among the membership and the wider community. Its seven-year scholarship programme (2006-2012) meets the secondary educational expenses of community orphans and the vulnerable children of its members.[7] 

Studies have also shown that the elements of self –reliance and collective action built into the cooperative model also allow women to develop social capital that would be otherwise difficult to attain. Membership in collective enterprises allows women to build both working and personal relations, often increasing their social standing.[8]Women members of collective organizations also often report increased self-esteem and a sense of solidarity and support, particularly in times of need.[9] 

Challenges faced

The benefits to women brought by cooperative enterprise are many, but they are not universal. Some social and cultural nuances within households and communities can serve to limit how much of women’s returns they are able to retain. Similar constraints may also affect their ability to organize as cooperatives at all. In agricultural cooperatives in many Asian countries, women account for only 2 to10.5 per cent of total membership.[10]In addition, as with any other form of enterprise, women’s cooperatives still face the challenges of quality production, access to markets, market-driven prices and fair legislation.

Beyond the rural experience

While much of the available research on women in cooperatives focuses on women producers, in rural areas in developing countries, it is easy to see how the benefits of cooperatives could translate to improved livelihoods for urban women as well. In Italy, evidence shows that the application of cooperative employment in the social economy not only provided decent work for otherwise vulnerable or transitional individuals but also imparted them with the labour force and entrepreneurial skills to further diversify their livelihood prospects.[11]This element of capacity building is one that would be useful to normally marginalized women whether as rural or urban dwellers.

The collective strength and increased self-esteem associated with cooperative membership is also useful in strengthening women’s capacity to defend and secure their rights to decent living and decent work. In the United States, women domestic workers have used cooperatives as a means of organizing themselves to ensure fair wages and reduce exploitation.[12] 

Overcoming the challenges

Cooperatives and other forms of collective enterprise already feature greatly in the structure of global agricultural production, particularly in developing countries. However, the benefits of cooperatives cannot be realized without attention to gender inequality. [13] Despite the heavy involvement of women in agricultural production, they are still not well represented in membership and leadership of agricultural cooperatives. Developing women’s only cooperatives provides a strategy for including women in the benefits of cooperative organizations while speaking to some of the nuances of culture and social practice that may otherwise inhibit their full inclusion. As such, where policies and programmes focus on women’s economic empowerment, self-employed women workers, and women producers should be made aware of the benefits to creating cooperatives or joining existing ones. At the same time, where the option to cooperative membership exists, but the barriers to full participation of women are high, efforts must be made to sensitize cooperative members and leaders to issues of women’s rights and the benefits of women’s full participation.

Where cooperatives are in place, and women’s membership is strong, capacity building is still essential for effective participation. Cooperatives cannot function effectively if their members are not fully aware of and adherent to the values and principles at the core of cooperative organization and other forms of collective enterprise. For members to be effective, they have to be aware of their rights and roles as members and effective ways for managing cooperative leadership. This is especially pertinent in women’s only cooperatives, and with women cooperative members in settings where women usually maintain subservient, less visible roles in the household and community. This sort of empowerment can increase women’s leadership in cooperatives.

Operationally, it is important that cooperative members, whether women or men, have adequate knowledge of productive, market and legal processes relevant to their field of work. It is especially important to emphasize this in strengthening the capacities of women cooperative members, in situations where women’s access to education and information may be limited.  More specifically ensuring that women’s cooperatives have equal and adequate access to extension services and relevant productive and communication technologies is vital.

Relatedly, ensuring access to credit for women’s only cooperatives is essential for them to be able to grow. This not only requires reviewing structural barriers to financing for women and/or cooperatives, but also promoting the pursuit of cooperative networks or associations that can further strengthen the assets base and creditworthiness of cooperatives in need of financing. In this regard, and others, it is important to establish clear avenues for dialogue between women’s cooperatives, governments and other stakeholders. This will ensure that governments and other stakeholders are more responsive to the particular needs of women’s cooperatives.

In short, promoting cooperative organization among women is a worthy strategy for self-empowerment, but it is not without its political, social and cultural challenges. An important balance must thus be struck between cooperative formation, individual and organizational capacity building, government support and promotion, and organizational autonomy if the full benefits to women and their families are to be realized.


[1]Food and Agriculture Organization of the United Nations. (2011). State of Food and Agriculture 2010-11. Women in

[2]Jones, Elaine; Sally Smith and Carol Wills. (2012). Women producers and the benefits of collective forms of enterprise.Gender and Development, 20:1, 13-32

[3]Amaza, P.S., P.V. Kwagbe, and A.A. Amos. 1999. Analysis of women participation in agricultural cooperatives: Case Study of Borno State, Nigeria. Annals of Borno 15/16:187-196.

[4]Datta, P. B. and Gailey, R. (2012), Empowering Women Through Social Entrepreneurship: Case Study of a Women’s Cooperative inIndia. Entrepreneurship Theory and Practice. doi: 10.1111/j.1540-6520.2012.00505.x

[5]Datta and Gailey. (2012).

[7]See the following website: http://kncutanzania.com/index.html

[8]World Bank, ood and Agricultural Organization,and International Fund for Agricultural Development. (2009). Gender in Agriculture Sourcebook, Washington, DC: World Bank.

[9]Jones, Smith and Wills. (2012).

[10]Prakash, D (Rural Development and Management Centre, New Delhi, India). (2003). Rural women, food security and agricultural cooperatives.Paper produced for presentation and to serve as a theme paper at the 4th  Asian-African International Conference on Women in Agricultural Cooperatives in Asia and Africa organised jointly by the ICA, AARRO, JA-Zenchu and IDACA at Tokyo, Japan. August 24-29 1999

[11]Savio, M. and Righetti, A. (1993), Cooperatives as a social enterprise inItaly: a place for social integration and rehabilitation. ActaPsychiatricaScandinavica, 88: 238–242.

[12]Estey, K. (2011), Domestic Workers and Cooperatives: BeyondCare goes beyond capitalism, A case study inBrooklyn,New York. WorkingUSA, 14:347-365.

[13] See discussion by Mayoux, L. (1992), From Idealism to Realism: Women, Feminism and Empowerment in Nicaraguan Tailoring Co-operatives. Development and Change, 23: 91–114.

Cooperatives and Social Justice

March 14, 2012 § Leave a comment

Cooperative and Social Justice

Cooperative and Social Justice

“If given the right supportive environment, cooperatives could help in profound ways to achieve social justice, where it is lacking.”

Throughout the world today, societies are been torn apart due to the fact that various social groups and classes are not getting their due respect from other forces in society. Societies for all are therefore a difficult reality to create and sustain. Social justice is an urgent need and demand in all regions of the world.

Many societies are lacking social justice which could be seen as equal opportunity treatment of all persons in society. It focuses on the dignity of each individual. Social justice promotes the participation each individual in the development of their society and to enjoy the rewards of that development. Various institutions have the responsibility to ensure this happens. Yet social justice is absent in many instances.

The significance of cooperatives for social justice

Cooperatives are based on principles and values that speak directly to the issue of social justice. Most traditional cooperatives follow the seven principles of cooperative identity, promoted by the International Cooperative Alliance (ICA), an Apex organization for cooperatives around the world.[1] These principles call for the practice of democracy, equality, equity and solidarity. Cooperatives also embrace the ethical values of honesty, openness, social responsibility and caring for others.

With these principles and values at the core of cooperative operations, the poor, excluded and marginalized sectors of society are usually served well by cooperatives. The financial sector is one area where this has shown well. Financial cooperatives are some of the largest providers of microfinance services to the poor. It is estimated that globally, financial cooperatives reach 78 million clients living below a poverty line of $2 per day. Financial cooperatives thus play a central role in the achievement of an inclusive financial sector that encompasses the poor.

Through their commitment to servicing the poor and underserved, financial cooperatives are helping to lessen the burden of poverty.  Financial cooperatives, by providing savings products, help to reduce members’ vulnerabilities to shocks such as medical emergencies. In Senegal, the health mutual, PAMECAS provides affordable insurance for savings and health care to disadvantaged and low-income families. [2] Similarly, the CIC Insurance Group in Kenya provides affordable insurance to populations left out by mainstream insurance companies. In addition to risk protection services for the poor and the disadvantaged, CIC is the largest provider of micro insurance in Kenya.[3]

Cooperatives have also been instrumental in promoting inclusive development in rural areas, helping to both strengthen and diversify rural economies. Financial cooperatives provide access to credit for members who might not typically have access to the larger savings and commercial banks. This is significant in markets where financial providers are absent owing to poor revenue prospects, high risks, or high transaction costs. This access to financial services often supports the formation of small and micro businesses.

Cooperatives have also been able to strengthen agricultural production and improve access of poor farmers, especially through engaging in fair trade arrangements. Small farmers who struggle to create and sustain businesses of their own are able to increase farm revenues, lower marketing and information-gathering costs, as well as enter into high-value supply chains that they would not be able to do on their own.

In Peru, the organizational and technological capacities of the Central Association of Small Producers of Organic Bananas, a cooperative operating under fair trade arrangements, enable it to promote fair trade in the commercial chain and diversify the productive system in a sustainable manner. In three years the Association’s profits have grown rapidly and it has strengthened food security and improved the social, economic, cultural and environmental situation of its members and community.  The 126 members of the Toledo Cacao Growers Association, in Belizerely on cocoa production for their income. For members, fair trade premiums have meant the difference between sending their children to school and keeping them at home to work. For the El Ceibo cacao cooperative in the PlurinationalStateof Bolivia, fair trade has brought new independence and empowerment to farmers who were previously shuffled from one flawed and exploitative agricultural exporting system to another.[4]

Strategic approaches to improve the work of cooperatives 

While the need for more research cannot be denied, that which exists supports the idea that, if given the right supportive environment, cooperatives could help in profound ways to achieve social justice, where it is lacking.

Empowering cooperatives to leverage their capacity to contribute to social justice requires a sound policy and legislative framework. Some guidance on this already exists. Governments adopted the United Nations guidelines on cooperatives in 2001. In 2002, governments also adopted ILO Recommendation No. 193, which emphasizes the need to promote the business potential of cooperatives so they can contribute to sustainable development and decent employment, in the context of the urgent need for social justice. While some countries have used these and other guidance to shape an effective policy environment for cooperatives enterprises more still needs to be done to create greater awareness of  these instruments at all decision-making levels.

The International Year of Cooperatives 2012, declared by the United Nations general Assembly, is one means to raising awareness. The IYC has been put in place not only to raise awareness of these existing instruments, but to raise awareness of the cooperative enterprise model and its potential contributions to social development. By raising awareness of cooperatives – what they are and what they do – the IYC will empower cooperatives to promote their social justice values and encourage governments to create supportive policy and legislative frameworks, where needed.

Even with this support, the challenge of effective implementation of the cooperative principles and values cannot be ignored. The sound governance of cooperatives depends upon a well-informed and active membership base, dedicated to cooperative values and principles. To sustain the drive of cooperatives for social justice, a strong membership base, bound by the democratic one-member-one-vote principle, is essential to addressing weak or unethical management, capture by local politicians, or other conflicts of interests which could divert cooperatives from addressing social justice issues.


[1] International Cooperative Alliance (n.d.) “Statement of the Co-operative Identity”. http://www.ica.coop/coop/principles.html
[2] Read more about PAMECAS at http://www.pamecas.org/
[3] Read more about the CIC insurance group at http://cic.co.ke/
[4] Read more about TCGA and El Ceibo at http://www.globalexchange.org/fairtrade/cocoa/cooperatives

Welcome!

January 22, 2012 § Leave a comment

Welcome to the Official United Nations Blog of the International Year of Cooperatives (IYC). Here you will find IYC Issues Briefs. This Blog is Private. It is by invitation only.

The United Nations General Assembly Resolution A/RES/64/136 encourages all member States, the United Nations and all relevant stakeholders to take advantage of the IYC to promote cooperatives and raise awareness of their contribution to social and economic development and promote the formation and growth of cooperatives. The resolution A/RES/64/136 – Proclamation of 2012 as International Year of Cooperatives is available in all UN six official languages: English | Français | Español | Русский | عربي | 汉语

The United Nations General Assembly Resolution A/RES/65/184 Invites all Member States to consider taking action towards establishing national mechanisms, such as national committees, to prepare for, observe and
follow up on the International Year of Cooperatives, in particular for the purpose of planning, stimulating and harmonizing the activities of the governmental and non-governmental agencies and organizations concerned with the preparations for and observance of the Year.
 English | Français | Español | Русский | عربي | 汉语

Goals of the International Year of Cooperatives             

  • Increase public awareness about cooperatives and their contributions to socio-economic development and the achievement of the Millennium Development Goals.
  • Promote the formation and growth of cooperatives
  • Encourage Governments to establish policies, laws and regulations conducive to the formation, growth and stability of cooperatives


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