It depends on the type of anarchist society you are talking about. Different anarchists propose different solutions.

In an individualist-mutualist society, for example, health care and other public services would be provided by individuals or co-operatives on a pay-for-use basis. It would be likely that individuals or co-operatives/associations would subscribe to various insurance providers or enter into direct contracts with health care providers. Thus the system would be similar to privatised health care but without the profit margins as competition, it is hoped, would drive prices down to cost.

Other anarchists reject such a system. They are favour of socialising health care and other public services. They argue that a privatised system would only be able to meet the requirements of those who can afford to pay for it and so would be unjust and unfair. The need for medical attention is not dependent on income and so a civilised society would recognise this fact. Under capitalism, profit-maximising medical insurance sets premiums according to the risks of the insured getting ill or injured, with the riskiest may not being able to find insurance at any price. Private insurers shun entire industries, such as logging, as too dangerous for their profits due to the likelihood of accidents or illness. They review contracts regularly and drop people who get sick. Hardly a vision to inspire a free society or one compatible with equality and mutual respect.

Moreover, competition would lead to inefficiencies as prices would be inflated to pay for advertising, competition related administration costs, paying dividends to share-holders and so on. For example, in 1993, Canada's health plans devoted 0.9% of spending to overhead, compared to U.S. figures of 3.2% for Medicare and 12% for private insurers. In addition, when Canada adopted its publicly financed system in 1971, it and the U.S. both spent just over 7% of GDP on health care. By 1990, the U.S. was up to 12.3%, verses Canada's 9%.

As can be seen, social anarchists point to what happens under capitalism when discussing the benefits of a socialised system of health care in an anarchist society. Competition, they argue, harms health-care provision. According to Alfie Kohn:

"More hospitals and clinics are being run by for-profit corporations; many institutions, forced to battle for 'customers,' seem to value a skilled director of marketing more highly than a skilled caregiver. As in any other economic sector, the race for profits translates into pressure to reduce costs, and the easiest way to do it here is to cut back on services to unprofitable patients, that is, those who are more sick than rich . . ."

He concludes:

"The result: hospital costs are actually higher in areas where there is more competition for patients." [Alfie Kohn, No Contest, p. 240]

As Robert Kuttner notes:

"The American health-care system is a tangle of inequity and inefficiency — and getting worse as private-market forces seek to rationalise it. A shift to a universal system of health coverage would cut this Gordian knot at a stroke. It would not only deliver the explicitly medical aspects of health more efficiently and fairly, but, by socialising costs of poor health, it would also create a powerful financial incentive for society as a whole to stress primary prevention. . . every nation with a universal system spends less of its GDP on health care than the United States . . . And nearly every other nation with a universal system has longer life spans from birth (though roughly equivalent life spans from adulthood) . . . most nations with universal systems also have greater patient satisfaction.

"The reasons . . . should be obvious. By their nature, universal systems spend less money on wasteful overhead, and more on primary prevention. Health-insurance overhead in the United States alone consumes about 1 percent of the GDP, compared to 0.1 percent in Canada. Though medical inflation is a problem everywhere, the universal systems have had far lower rates of cost inflation . . . In the years between 1980 and 1987, total health costs in the United States increased by 2.4 times the rate of GDP growth. In nations with universal systems, they increased far more slowly. The figures for Sweden, France, West Germany, and Britain were 1.2, 1.6, 1.8, and 1.7 percent, respectively . . .

[. . . ]

"Remarkably enough, the United States spends most money on health care, but has the fewest beds per thousand in population, the lowest admission rate, and the lowest occupancy rate — coupled with the highest daily cost, highest technology-intensiveness, and greatest number of employees per bed." [Everything for Sale, pp. 155-6]

In 1993, the US paid 13.4% of its GDP towards health care, compared to 10% for Canada, 8.6% for Sweden and Germany, 6.6% for Britain and 6.8% for Japan. Only 40% of the US population was covered by public health care and over 35 million people, 14% of the population, went without health insurance for all of 1991, and about twice that many were uninsured for some period during the year. In terms of health indicators, the US people are not getting value for money. Life expectancy is higher in Canada, Sweden, Germany, Japan and Britain. The USA has the highest levels of infant mortality and is last in basic health indicators as well as having fewer doctors per 1,000 people than the OECD average. All in all, the US system is miles begin the universal systems of other countries.

Of course, it will be argued that the USA is not an anarchy and so comparisons are pointless. However, it seems strange that the more competitive system, the more privatised system, is less efficient and less fair than the universal systems. It also seems strange that defenders of competition happily use examples from "actually existing" capitalism to illustrate their politics but reject negative examples as being a product of an "impure" system. They want to have their cake and eat it to.

Therefore, most anarchists are in favour of a socialised and universal health-care system for both ethical and efficiency reasons. Needless to say, an anarchist system of socialised health care would differ in many ways to the current systems of universal health-care provided by the state.

Such a system of socialised health-care will be built from the bottom-up and based around the local commune. In a social anarchist society, "medical services . . . will be free of charge to all inhabitants of the commune. The doctors will not be like capitalists, trying to extract the greatest profit from their unfortunate patients. They will be employed by the commune and expected to treat all who need their services." Moreover, prevention will play an important part, as "medical treatment is only the curative side of the science of health care; it is not enough to treat the sick, it is also necessary to prevent disease. That is the true function of hygiene." [James Guillaume, Bakunin on Anarchism, p. 371]

How would an anarchist health service work? It would be based on self-management, of course, with close links to the local commune and federations of communes. Each hospital or health centre would be autonomous but linked in a federation with the others, allowing resources to be shared as and when required while allowing the health service to adjust to local needs and requirements as quickly as possible.

The Spanish Revolution indicates how an anarchist health service would operate. In rural areas local doctors would usually join the village collective and provided their services like any other worker. Where local doctors were not available, "arrangements were made by the collectives for treatment of their members by hospitals in nearby localities. In a few cases, collectives themselves build hospitals; in many they acquired equipment and other things needed by their local physicians." For example, the Monzon comercal (district) federation of collectives in Aragon established maintained a hospital in Binefar, the Casa de Salud Durruti. By April 1937 it had 40 beds, in sections which included general medicine, prophylaxis and gynaecology. It saw about 25 outpatients a day and was open to anyone in the 32 villages of the comarca. [Robert Alexander, The Anarchists in the Spanish Civil War, vol. 1, p. 331 and pp. 366-7]

The socialisation of the health care took on a slightly different form in Catalonia but on the same libertarian principles. Gaston Leval provides us with an excellent summary:

"The socialisation of health services was one of the greatest achievements of the revolution. To appreciate the efforts of our comrades it must be borne in mind that the rehabilitated the health service in all of Catalonia in so short a time after July 19th. The revolution could count on the co-operation of a number of dedicated doctors whose ambition was not to accumulate wealth but to serve the afflicted and the underprivileged.

"The Health Workers' Union was founded in September, 1936. In line with the tendency to unite all the different classifications, trades, and services serving a given industry, all health workers, from porters to doctors and administrators, were organised into one big union of health workers

[. . .]

"Our comrades laid the foundations of a new health service . . . The new medical service embraced all of Catalonia. It constituted a great apparatus whose parts were distributed according to different needs, all in accord with an overall plan. Catalonia was divided into nine zones . . . In turn, all the surrounding villages and towns were served from these centres.

"Distributed throughout Catalonia were twenty-seven towns with a total of thirty-sex health centres conducting services so thoroughly that every village, every hamlet, every isolated peasant in the mountains, every woman, every child, anywhere, received adequate, up-to-date medical care. In each of the nine zones there was a central syndicate and a Control Committee located in Barcelona. Every department was autonomous within its own sphere. But this autonomy was not synonymous with isolation. The Central Committee in Barcelona, chosen by all the sections, met once a week with one delegate from each section to deal with common problems and to implement the general plan. . .

"The people immediately benefited from the projects of the health syndicate. The syndicate managed all hospitals and clinics. Six hospitals were opened in Barcelona. . . Eight new sanitariums were installed in converted luxurious homes ideally situated amidst mountains and pine forests. It was no easy task to convert these homes into efficient hospitals with all new facilities. . ." [quoted by Sam Dolgoff, The Anarchist Collectives, pp. 99-100]

People were no longer required to pay for medical services. Each collective, if it could afford it, would pay a contribution to its health centre. Building and facilities were improved and modern equipment introduced. Like other self-managed industries, the health service was run at all levels by general assemblies of workers who elected delegates and hospital administration.

In the Levante, the CNT built upon its existing Sociedad de Socorros Mutuos de Levante (a health service institution founded by the union as a kind of mutual benefit society which had numerous doctors and specialists). During the revolution, the Mutua had 50 doctors and was available to all affiliated workers and their families.

Thus, all across Spain, the workers in the health service re-organised their industry in libertarian lines and in association with the local collective or commune and the unions of the CNT. As Gaston Leval summarises:

"Everywhere that we were able to study the towns and little cities transformed by the revolution, the hospitals, the clinics, the polyclincs and other health establishments have been municipalised, enlarged, modernised, put under the safekeeping of the collectivity. And where they didn't exist, they were improvised. The socialisation of medicine was a work for the benefit of all." [quoted by Robert Alexander, Op. Cit., p. 677]

We can expect a similar process to occur in the future anarchist society. Workers in the health industry will organise their workplaces, federate together to share resources and information, to formulate plans and improve the quality of service to the public. The communes and their federations, the syndicates and federations of syndicates will provide resources and effectively own the health system, ensuring access for all.

Similar systems would operate in other public services. For example, in education we expect the members of communes to organise a system of free schools. This can be seen from the Spanish revolution. Indeed, the Spanish anarchists organised Modern Schools before the outbreak of the revolution, with 50 to 100 schools in various parts funded by local anarchist groups and CNT unions. During the revolution everywhere across Spain, syndicates, collectives and federations of collectives formed and founded schools. Indeed, education "advanced at an unprecedented pace. Most of the partly or wholly socialised collectives and municipalities built at least one school. By 1938, for example, every collective in the Levant Federation had its own school." [Gaston Leval, quoted by Sam Dolgoff, The Anarchist Collectives, p. 168] These schools aimed, to quote the CNT's resolution on Libertarian Communism, to "help mould men with minds of their own — and let it be clear that when we use the word 'men' we use it in the generic sense — to which end it will be necessary for the teacher to cultivate every one of the child's faculties so that the child may develop every one of its capacities to the full." [quoted by Jose Periats, The CNT in the Spanish Revolution, p. 70] The principles of libertarian education, of encouraging freedom instead of authority in the school, was applied on vast scale (see section J.5.13 for more details on Modern Schools and libertarian education).

This educational revolution was not confined to collectives or children. For example, the Federacion Regional de Campesinos de Levante formed institutes in each of its five provinces. The first was set up in October 1937 in an old convent with 100 students. The Federation also set up two "universities" in Valencia and Madrid which taught a wide variety of agricultural subjects and combined learning with practical experience in an experimental form attached to each university. The Aragon collectives formed a similar specialised school in Binefar. The CNT was heavily involved in transforming education in Catalonia. In addition, the local federation of the CNT in Barcelona established a school to train women workers to replace male ones being taken into the army. The school was run by the anarchist-feminist group the Mujeres Libres. [Robert Alexander, Op. Cit., p. 406, p. 670 and pp. 665-8 and p. 670]

Ultimately, the public services that exist in a social anarchist society will be dependent on what members of that society desire. If, for example, a commune or federation of communes desires a system of communal health-care or schools then they will allocate resources to implement it. They will allocate the task of creating such a system to, say, a special commission based on volunteers from the interested parties such as the relevant syndicates, professional associations, consumer groups and so on. For example, for communal education a commission or working group would include delegates from the teachers union, from parent associations, from student unions and so on. The running of such a system would be based, like any other industry, on those who work in it. Functional self-management would be the rule, with doctors managing their work, nurses theirs and so on, while the general running of, say, a hospital would be based on a general assembly of all workers there who would elect and mandate delegates, the administration staff and decide the policy the hospital would follow. Needless to say, other interested parties would have a say, including patients in the health system and students in the education system.

Thus, as would be expected, public services would be organised by the public, organised in their syndicates and communes. They would be based on workers' self-management of their daily work and of the system as a whole. Non-workers who took part in the system (patients, students) would not be ignored and would also place a role in providing essential feedback to assure quality control of services and to ensure that the service is responsive to users needs. The resources required to maintain and expand the system would be provided by the communes, syndicates and their federations. For the first time, public services would truly be public and not a statist system imposed upon the public from above.

Needless to say, any system of public services would not be imposed on those who did not desire it. They would be organised for and by members of the communes. Therefore, individuals who were not part of a local commune or syndicate would have to pay to gain access to the communal resources. However, it is unlikely that an anarchist society would be as barbaric as a capitalist one and refuse entry to cases who were ill and could not pay, nor turn away emergencies because they did not have enough money to pay. And just as other workers need not join a syndicate or commune, so doctors, teachers and so on could practice their trade outside the communal system as either individual artisans or as part of a co-operative. However, given the availability of free medical services it is doubtful they would grow rich doing so. Medicine, teaching and so on would revert back to what usually initially motivates people to take these up professions — the desire to help others and make a positive impact in peoples lives.