Sometimes it takes a pandemic to really focus the collective attention. To be sure, concerns about the decline of health and social care programmes have been ongoing for decades. The industrialised societies of Europe and North America were the first to institute what we recognise as the welfare state, a model of collective social welfare that soon became the gold standard for a modern democracy. What the pandemic has revealed is just how far that idealised notion of the welfare state has fallen. Decades of privatisation and austerity policies have hollowed out what were once established baselines for publicly funded health and social services.

Beginning in Bismarck's Germany, where the first social security programmes were established, up to the high point of public health and social care programmes instituted by the United Kingdom (UK) and the Nordic countries in the post-war era, social welfare seemed a reliable measure of progress towards greater social and economic equity. Neoliberalism and the free market policies of the Reagan– Thatcher governments put an end to that. The state, once the guarantor of public health and social welfare, became the mechanism by which public programmes – or more accurately, public assets built with tax money – were increasingly privatised and remade into sources of private profit.

Today, with the failures of privatised health and social care coming into full view, the state has once again been thrust into the role of guarantor of the public welfare. The COVID-19 pandemic has spurred renewed calls for bringing health and social care fully back under state control. But is this really the answer we need in the 21st century? Was it not the state itself that presided over the destruction of these very programmes by turning them over to the private sector? What would prevent the state from doing so again? Given the rollercoaster history of social welfare over the past 50 years, we are in need of alternatives.

For all the undeniable benefits that the welfare state brought to public health and welfare, it is easy to forget the deficiencies that came with it. The bureaucratisation of care brought a host of new problems, pitting the inflexible demands of centralised management systems against the individual needs of citizens and communities. State welfare presupposed anonymity and powerlessness – and poverty. The human and social factors of care were all but erased.