F Summary and Conclusions - Two Kinds of Co-production

The analysis of data from the Patient Study was based on a model of patient needs, hospital structures and enhancing institutions that can promote patient participation and influence and their service

Table 7.4 How satisfied are you with the staff and hospital services in general?

Are you satisfied with the hospital and staff /

Med Co-ops



Administrative Staff-1




Professional Staff1




Healthcare Services (In General)












  • * Combinesthe ‘satisfied’ and ‘somewhat satisfied’ answers;
  • ** ConsultTable 7.B in the appendix for missing data in this table; and *** Difference between the Medical Co-ops and Koseiren-, a = Reception, accounting, information, etc. and b = Doctors and nurses.

satisfaction. It was argued that the results from the Patient Study suggest the existence of two different kinds of co-production, aspirational and transformative. Table 7.1 showed that instrumental motivations weigh heavily for Koseiren patients in the choice of their healthcare provider. Ease of access and necessity are mentioned by virtually all of them. The reputation of the hospital or staff for being ‘kind and helpful’ or considered ‘competent’ motivated more than half of the patients at Koseiren hospitals and two-thirds of patients at the Medical Co-ops. In addition, Medical Co-op patients attach greater importance in their co-op membership when choosing a healthcare provider.

Table 7.2 showed that Medical Co-op patients participated more actively in most types of hospital events. It also illustrated some features of health literacy outreach that both the Medical Co-ops and Koseiren share. In addition, the Medical Co-op patients noted several channels that facilitate member participation in running the health coops. In particular, this included making investments in their healthcare provider via a membership contribution, participating in community activities, attending local membership meetings and participating in volunteer activities. Table 7.3 underlined that Medical Co-op patients also felt more capable of and willing to express their opinion about the hospital and its services. They also found additional channels for expressing their opinions through committee meetings and by attending local co-op meetings. Table 7.4 demonstrates that patients at both hospital groups were generally quite satisfied with the hospital’s staff and services, but Medical Co-op patients were slightly more satisfied than Koseiren patients on all matters except for accessibility to the hospital or clinic itself. Finally, nearly the same proportion of patients at both hospital groups - more than two-thirds of them - stated they would recommend it to friends or acquaintances.

The Patient Study addresses issues related to the importance of membership. Does being a patient in a Medical Co-op mean the same thing as being a patient at a Koseiren hospital? Data presented in the Patient Study suggest that it does not. Patients at the Medical Co-ops are more than just patients; they are also members of their healthcare co-op. Being a member creates ties that bind. It also provides them with a feeling of ownership that gives them certain rights and responsibilities that are not shared by nonmembers. Thus, membership provides the social glue that enables and facilitates their working together for a common goal (i.e. their individual and collective health and well-being).

The comparison of patient participation in Medical Co-ops and Koseiren healthcare providers demonstrates that there are different levels and different kinds of patient participation when patients are members in health co-ops rather than simply patients or clients at a hospital. Although, both hospital groups seem to embrace an active stance in terms of health literacy outreach. Patients at both hospital groups note similar levels of participation in hospital festivals and study groups for health issues. This begs the question: What can hospitals do to encourage and facilitate patient participation? Direct membership in health co-ops seems to comprise the key of an active organizational culture that, combined with social support structures, can promote patient activism in addition to high health literacy via the health study groups. Thus, both organizational culture and social support appear to enable and facilitate the manifestation of transformative co-production at the micro-level of single healthcare providers.

The Medical Co-ops promote active participation by patients in a variety of ways, and they have institutions that can facilitate and foster their inclusion in the internal workings of their healthcare provider. By expecting patients to become a member of the health co-op, the Medical Co-ops are able to extend the rights and responsibilities of membership in a very different fashion than in Koseiren, since it lacks direct individual patient members. Thus, membership in a health co-op provides a key to facilitating and fostering active patient participation at the Medical Co-ops. Patients who are direct members of health co-ops have more positive attitudes about several aspects of the healthcare services, and they are more active in the provision of their own healthcare.

These two different approaches to co-production not only express two different patterns of patient involvement in the provision of healthcare. They also represent the differing needs of their patients. In rural areas, utilitarian or instrumental needs to alleviate local shortages in healthcare services and create qualified jobs locally are understandably much greater. Therefore, members of agricultural co-ops are satisfied with the traditional healthcare services provided by Koseiren. In urban areas, however, the need for more engagement and activity by some groups manifests itself, and health co-op members appear equally satisfied with the services provided by the Medical Co-ops. Nevertheless, they have the possibility' of challenging traditional relationships of power, control and expertise in healthcare, rendering it the joint product of the activities of both patients and professional healthcare providers.

Thus, the Patient Study illustrates that there are two kinds of coproduction: aspirational and transformative. Aspirational co-production is limited to describing and recognizing the potential benefits of coproduction, paying lip service to it and accepting some marginal or ad hoc contributions by citizens to public services. This may include finding ways to gradually increase the input of citizens to the provision of healthcare in one fashion or another. However, it does not call into question or challenge the power asymmetry between the professional service providers and citizens. Transformative co-production, on the other hand, includes encouraging co-production by actively facilitating, fostering and institutionalizing it. This leads to the conclusion that, if a healthcare provider wants to embrace transformative co-production in the 21st Century, then it must develop a proactive strategy for encouraging patients to participate actively in their own healthcare, both individually and collectively, and a sustainable policy to facilitate and implement it. However, there is no quick fix, since opening an organization for transformative co-production can be a lengthy and complicated process.

Whether transformative co-production at the level of an individual healthcare provider is sufficient to facilitate co-production at the meso and/or macro levels remains to be seen. This will be given more attention in Chapter 11. However, studies of citizen participation in the provision of publicly financed services in Sweden and Japan help illustrate the breadth and depth of the steps necessary to achieve transformative co-production. In Sweden, parents in parent co-op childcare and voluntary organizations with a special pedagogical profile are responsible for the management and maintenance of the childcare facility and balancing its budget, or they can share these responsibilities with the staff. By contrast, parents at worker co-ops and public childcare facilities can contribute to the Christmas or Spring party and make ad hoc suggestions for daily activities or improvements at the facility. Sometimes, they are represented on a parent council that meets every second or third month to discuss issues or make suggestions for changes. However, they have no vote and cannot decide such matters. Thus, there is a ‘glass ceiling’ that limits their participation (Pestoff, 1998); their influence is rather limited, and it does not challenge or change the power balance between the professional service providers and service recipients. However, including parents on the board of worker co-ops and giving them both a voice and vote would provide a means to transform them into multi-stakeholder organizations and imply adopting a different governance model.

Similarly, patients at Medical Co-op hospitals share the rights and responsibilities of membership in a health co-op that gives them a privileged position vis-a-vis that of simply being a patient. They value their Medical Co-op mostly in terms of expressive rather than instrumental values as will be seen in Chapter 10 They are involved in a variety of the manifestations and inner workings of their health co-op - in particular, community activities and local membership meetings. They also volunteer at the hospital and they make donations to and investments in its health promotion activities. Moreover, in addition to talking with the professional staff and using the suggestion box, they can gain influence by voicing their opinion at a committee meeting, attending a local health co-op meeting, etc.

Furthermore, health co-op members are encouraged to join ban study groups in order to bring their diet, exercise and lifestyle into balance as part of their effort to promote preventive medicine. Members are also recruited to relevant hospital committees, and many of them are board members and/ or even lay hospital directors. Such opportunities both foster and institutionalize the role of members as co-producers of their own and others’ healthcare. These opportunities are not available to the patients at hospitals lacking these structures. They do not have the rights and responsibilities of health co-op members, rather they are simply hospital patients. Lacking the features of transformative co-production, they are part and parcel of an incremental and instrumental approach to co-production. Moreover, given the hierarchical command and control model of governance found in public healthcare, co-production in public hospitals will most likely be limited to lower levels of the aspirational variety of co-production (McMullin, 2020). Nevertheless, these two different approaches to co-production might have something to learn from each other in terms of best practices. This points to the importance of the governance models employed by hospital groups and the social values they promote in their activities in order to more fully understand their unique contribution to Japanese healthcare. Governance is the topic of Chapter 9, while social values and hospital missions are the focus of Chapter 10.

Finally, this suggests that governments need to develop more flexible, service-specific and organization-specific approaches for promoting coproduction in healthcare - particularly, collective co-production - rather than looking for simple ‘one-size-fits-all’ solutions to the challenges facing public service delivery. This is notably relevant for enduring services, like healthcare, where sustainable patient participation is crucial for resolving the mounting challenges posed by chronic illness.


1 The data collection was financed by the Japanese Society' for the Promotion of Science (JSPS), the Mitsubishi Foundation and Osaka University; and it was supervised by Prof. Yayoi Saito, Osaka University and the Consumer Cooperative Institute of Japan (CCIJ). The project is conducted within the framework of established cooperation between senior researchers at Ersta Skondal Bracke University' College in Stockholm (Prof. V. Pestoff and Doc. J. Vamstad) and the Faculty of Human Sciences, Osaka University' (Prof. Y. Saito). This interdisciplinary group of Swedish and Japanese researchers is supported by a reference group of the relevant cooperative healthcare providers in Japan, Koseiren and the Japanese Health and Welfare Co-operative Federation HeW CO-OP JAPAN.

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