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. In addition, such systems would have higher overheads (the need to pay share-holders and the high wages of upper management, most obviously, and not to mention paying for propaganda against “socialised” medicine) as well as charge more (privatised public utilities under capitalism have tended to charge consumers more, unsurprisingly as by their very nature they are natural monopolies).
Looking at health care, for example, 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 and most ill not being able to find insurance at any price. Private insurers shun entire industries as too dangerous for their profits due to the likelihood of accidents or illness. They review contracts regularly and drop sick people for the slightest reason (understandably, given that they make profits by minimising pay-outs for treatment). Hardly a vision to inspire a free society or one compatible with equality and mutual respect.
Therefore, most anarchists are in favour of a socialised and universal health-care system for both ethical and efficiency reasons (see section I.4.10). 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 (which, while called socialised medicine by its enemies is better described as nationalised medicine — although it should be stressed that this is better than the privatised system). 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, “On Building the New Social Order”, pp. 356–79, Bakunin on Anarchism, p. 371] The same would go for other public services and works.
While rejecting privatisation, anarchists also reject nationalisation in favour of socialisation and worker’s self-management. In this we follow Proudhon, who argued that there was a series of industries and services which were “public works” which he thought best handled by communes and their federations. Thus “the control undertaking such works will belong to the municipalities, and to districts within their jurisdiction” while “the control of carrying them out will rest with the workmen’s associations.” This was due to both their nature and libertarian values as the “direct, sovereign initiative of localities, in arranging for public works that belong to them, is a consequence of the democratic principle and the free contract: their subordination to the State is … a return to feudalism.” Workers’ self-management of such public workers is, again, a matter of libertarian principles for “it becomes necessary for the workers to form themselves into democratic societies, with equal conditions for all members, on pain of a relapse into feudalism.” Railways should be given “to responsible companies, not of capitalists, but of WORKMEN.” [General Idea of the Revolution, p. 276, p. 277 and p. 151]
This was applied during the Spanish Revolution. Gaston Leval discussed “Achievements in the Public Sector” in his classic account of the collectives. Syndicates organised water, gas and electricity utilities in Catalonia, while the trams and railways were run more efficiently and cheaper than under capitalist management. All across Spain, the workers in the health service re-organised their industry on libertarian lines and in association with the collectives, communes and the unions of the CNT. As Leval summarised:
“For the socialisation of medicine was not just an initiative of militant libertarian doctors. Wherever we were able to make s study of villages and small towns transformed by the Revolution, medicine and existing hospitals had been municipalised, expanded, placed under the aegis of the Collective. When there were none, they were improvised. The socialisation of medicine was becoming everyone’s concern, for the benefit of all. It constituted one of the most remarkable achievements of the Spanish Revolution.” [Collectives in the Spanish Revolution, p. 278]
So 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]
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. The socialisation of the health care took on a slightly different form in Catalonia but on the same libertarian principles. Gaston Leval provided 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 they 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-six 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 sanatoriums 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.” [The Anarchist Collectives, Sam Dolgoff (ed.), 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.
We can expect a similar process to occur in the future anarchist society. 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. 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 in a system of generalised self-management and socialisation. 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, Op. Cit., 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 anarcha-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, like any other industry, by 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 the administration staff and decide the policy the hospital would follow. Other interested parties would have a say, including patients in the health system and students in the education system. As Malatesta argued “the carrying out and the normal functioning of public services vital to our daily lives would be more reliable if carried out … by the workers themselves who, by direct election or through agreements made with others, have chosen to do that kind of work and carry it out under the direct control of all the interested parties.” [Anarchy, p. 41]
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 and so individuals who were not part of one would have to pay to gain access to communal resources. However, it is unlikely that an anarchist society would be as barbaric as a capitalist one and refuse entry to people who were ill and could not pay, nor turn away emergencies because they did not have enough money. 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 motivates people to initially take these up professions — the desire to help others and make a positive impact in society.
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, etc.) would not be ignored and would also play a role in providing essential feedback to assure quality control of services and to ensure that it 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 nor a system by which the few fleece the many by exploiting natural monopolies for their own interests.
So Public Services in a free society will be organised by those who do the work and under the effective control of those who use them. This vision of public services being run by workers’ associations would be raised as a valid libertarian reform under capitalism (not to mention raising the demand to turn firms into co-operatives when they are bailed out during an economic crisis). Equally, rather than nationalisation or privatisation, public utilities could be organised as a consumer co-operative (i.e., owned by those who use it) while the day-to-day running could be in the hands of a producer co-operative.