The Promise and the Power of Social Cooperatives

The democratization of social care realigns the roles of state and civil society within a larger framework of social and political transformation. Social cooperatives are a prime example of how cooperative values are rehumanizing social care by restoring the social and interpersonal relations that are its foundation.
—John Restakis, Civilizing the State

In response to neoliberal efforts to roll back state social service provision, a new type of social care has emerged. Known as “solidarity cooperatives” in Canada and “social cooperatives” in Italy, these community-led enterprises deliver high-quality childcare, eldercare, and disability care, among other offerings. (Nor are Canada and Italy alone, as this past NPQ article on South Korea details.)

In these countries, the key to delivering high-quality care is the multi-stakeholder nature of these cooperatives. Operating as democratic workplaces, the care services are co-created by providers and recipients, as well as community members, funders, and family members. This collaborative approach ensures that services are tailored to meet the actual needs of the community.

The two examples highlighted here illustrate this capacity for social innovation, both in devising a different approach to providing care and in operating with agility in service offerings.

A Care Cooperative in Quebec City Meets Community Health Needs

This year’s Cigale music festival, held over three days in August at Baie de Beauport beach in the Port of Quebec, was a great success. But such events are also known as possible occasions for tragedies involving drug overdoses, particularly from fentanyl.

This is why festivalgoers may have noticed a mobile van from the local solidarity cooperative SABSA. SABSA, an acronym from the French phrase for “low-threshold accessibility services,” plays a critical role in harm reduction by identifying the composition of the drugs people are consuming.

The SABSA healthcare cooperative is one of over 11,000 enterprises in the province of Quebec’s distinctive social economy.“We can both provide healthcare and do substance testing,” explained SABSA clinical nurse Marie-Odyle Massé to NPQ. “We also provide psychosocial intervention and a program of supervised safe consumption,” the latter offering specifically aimed at harm prevention.

The origins of SABSA go back to December 2011, during an epidemic of hepatitis C and HIV/AIDS that was taking a toll in lower Quebec City. A group of two clinical nurses and three social workers came together to address the needs of people they saw going untreated daily—individuals living on city streets and choosing not to go to a hospital.

Many suffered from addictions, as well as hepatitis C or HIV/AIDS, and some, especially immigrants, lacked a government health card despite Canada’s national healthcare system. Fear and shame were preventing them from getting needed care.

Initially working without pay, the care team formed a solidarity cooperative—a democratically governed service organization with three categories of members: users (people receiving the healthcare services), working members (people delivering the services), and supporting members (people supporting the services and operations).

The goal of the co-op was to provide quality local health services, disease prevention, and frontline care guided by a humanistic and pragmatic philosophy. Clients would participate in co-creating their care, which was interdisciplinary and delivered with an emphasis on harm reduction (as in the case of the co-op’s supervised injection site).

For the first few years, SABSA had minimal funding before finally receiving a grant from a nurses’ union in 2014, which allowed the organization to continue operating at a time when the sustainability of the group was in doubt. Once a research grant demonstrated the model’s effectiveness, the clinic’s value became more widely understood. The provincial government agreed to help underwrite worker salaries.

That same year also brought pushback from the local physicians’ association and the Ministry of Health over the responsibilities SABSA workers were taking on—prescribing, asking for lab tests, and making specialist referrals. These were tasks usually reserved for general practitioners.

SABSA team member Emmanuelle Lapointe and SABSA Foundation board member Mario Trudel pointed out in interviews with NPQ that patients would suffer if staff couldn’t make referrals. Subsequently, the health minister agreed to give the clinic a special status, encouraging the launch of more “super-nurse” clinics across Quebec.

Remarkably, SABSA data indicate that in 95 percent of cases, no follow-up with a general practitioner has been needed.

Moreover, SABSA is now partnered with Quebec City’s local health systems. The SABSA cooperative team of 13 includes nurse practitioners, social psychology internists, a visiting psychiatrist, a gastroenterologist, infectious disease specialists, external general practitioners, and a public health specialist. Nurse practitioners earn approximately the same salaries as their peers elsewhere but in a very different working environment, given the democratic nature of solidarity cooperatives. As a further aid to helping people stop using drugs, SABSA benefits from a group of member volunteers who are former patients.

SABSA’s programs include a clinic, a mobile health unit, and a supervised injection unit, as well as some wraparound services in areas like housing. Membership in SABSA costs ten Canadian dollars but can be waived in cases of need.

“Only by knowing the city and talking to people can you begin to think about how to create a cooperative.”

The governance model for solidarity co-ops is a multi-stakeholder approach. The clinic’s board comprises members from all three aforementioned categories. In 2018, SABSA also established its own foundation, which operates independently from the clinic, to generate additional financial support.

Trudel notes that SABSA’s annual budget today is C$1.7 million, about 61 percent of which comes from the regional government, with another 24 percent from the provincial Ministry of Health, the SABSA Foundation, businesses, and individual donors. The remaining 14 percent comes from pharmaceutical companies and pharmacies.

The work of SABSA demonstrates the capacity of nurse practitioners to manage patients with these conditions. As Lapointe explained, “We form an interdisciplinary team with professionals who have an interest in working with people in these vulnerable contexts. In this way, our nurses create connections with specialists in hospital settings. We also mentor nurse practitioners and have nursing and social work students.”

The SABSA healthcare cooperative is one of over 11,000 enterprises in the province of Quebec’s distinctive social economy—an economy that produces returns for the local community and protects the common good. Some 220,000 Quebecers are employed in this “third sector,” which generates almost C$48 billion (US$35 billion) in annual sales.

A Social Cooperative Offers a Leg Up for Workforce Integration in Milan, Italy

Among Italy’s 11,000 social cooperatives, one bright star is the Pandora social co-op. Pandora was founded in 2012 in Baranzate, a northern suburb of Milan by a group called NOA, which works with recovering alcoholics. Since then, the co-op has evolved to become a key player in workforce reintegration.

As Pandora’s president Davide Damiano explained to NPQ, after initially launching a piadineria (a cafe making flatbreads), the small team shifted to a cleaning service, eventually adding a program of five workshops teaching different levels of technical skills for specific contract work in Milan’s Monza prison, offered in both the men’s and women’s units. The work includes basic tasks like assembly and packaging but also trade school-type training, which can lead to better jobs.

In the Italian system, Pandora falls into the category of a type B co-op, one focused specifically on workforce reintegration for marginalized groups. Pandora also offers a “mobile office”—a vehicle that tours the neighborhoods, offering help and connection to those needing social services. The co-op partners with the Eris Foundation, also based in Milan, for these services.

“Only by knowing the city and talking to people can you begin to think about how to create a cooperative,” Damiano said.

In 2022, Pandora did something a bit unusual from the perspective of most social care service organizations. The co-op acquired the startup business Streeteat—a mobile restaurant—with an eye toward positioning the business to take advantage of the economic opportunities of the upcoming 2026 Winter Olympics in Milan.

The co-op is now up to 100 employees, of whom 70 percent are from disadvantaged communities—people formerly addicted to drugs, people who were or are incarcerated, and others. According to Damiano, the recidivism rate among co-op workers is 12 percent, as opposed to a national rate in Italy of 68 percent.

Italian law mandates quotas for employing workers with disabilities by companies of a certain size, and requires professional training and workplace accommodation for those workers. For companies with more than 50 employees, that quota is at least 7 percent of their total workforce.

By democratizing care and making it community led, practitioners and care recipients get the benefit of a bottom-up, localized approach.

A provision of that legislation allows social co-ops like Pandora to subcontract with companies to help them fulfill the requirement. “This work is not just about job creation,” Damiano noted, “the goal is reintegration into society.”

Pandora’s two membership categories are worker-members (including Damiano and several others in paid staff roles) and member volunteers. Decisions are made by Pandora’s board members with the staff included in the decision-making.

Worker-members participate in decisions, vote on board membership, and approve the financial balance sheet. Damiano notes that they also use a “social balance sheet” to help measure social impact alongside financial performance.

Pandora’s capacity to acquire other small businesses and then deploy them for its social purposes requires a kind of entrepreneurial savvy that would be unfamiliar to most US nonprofits. While part of this unfamiliarity is perhaps due to the IRS’s constraints around engaging in profit-making activities, it may also come from the two distinct cultures of our nonprofit and for-profit sectors.

Interestingly, in 2018 Pandora decided to forego all contracting with public entities. Damiano is among those Italian social entrepreneurs who share the view that social co-ops must try to stand independently without excessive reliance on either state contracts or private charity. He noted that Pandora is actively involved in Milanese politics and collaborates with other advocacy groups in the city focused on public policy.

“We must demonstrate to the world that even so-called disadvantaged people can perform the work as well or even better than others,” Damiano said. “If a social co-op develops its business relying solely on public funding, it makes a huge mistake; the day the contract is awarded to another operator or is no longer funded, the co-op will have to close.”

Implications for the United States

These examples from Quebec City and Milan reveal how local ecosystems of support have come together to create a different kind of social care. By democratizing care and making it community led, practitioners and care recipients benefit from a bottom-up, localized approach to these services.

Could the social cooperative model be imported to the United States? Some, like the Rocky Mountain Employee Ownership Center, aim to do so. The Colorado-based nonprofit has called for a movement to “bring social cooperatives to the US” and has created an eight-week training course predicated on the social co-op model.

For now, no legal category like the social cooperatives of Italy or the solidarity cooperatives of Quebec exists in the United States. This means that co-ops are either set up with bylaws that specify multiple membership categories—known as multi-stakeholder cooperatives or are structured as limited liability corporations.

Then again, the efforts in Italy and Quebec are relatively new. The enabling legislation in Italy dates from 1991. The Quebec law is even more recent—the category of solidarity cooperatives was created in 1997. In that short time, a sector numbering more than 10,000 businesses has developed in that province alone. The potential for similarly explosive development in the United States, building on emerging models, is possible.