The usefulness of neoliberalism as a theoretical concept in health research has been debated. This paper argues that when the concept of neoliberalism is used precisely and concretely, it provides an important and valid framework to analyse how health systems have been transformed over the last several decades. This claim is illustrated through the case of the Irish nursing home sector, which, over the last 20 years, has been turned upside down: from a mostly public system, it has been restructured into a mostly private, for-profit one. Privatisation, a quintessential neoliberal outcome, is analysed in detail. It was fostered by several neoliberal policies and has benefitted Irish (and to some extent global) economic elites. Tax incentives for private home operators and government budgetary constraints have limited state involvement in service provision and supported the expansion of the private sector. Private home staff are subject to more ‘flexible’ working conditions, which benefits employers. Moreover, the government plans to build new public nursing homes via public–private partnerships, which amount to privatisation. Also, global nursing home chains have begun to enter the Irish market, which offers profitable opportunities to international investors. However, international research shows that quality of care tends to be lower in private homes, due to cost cutting to increase profits.
Neoliberalism is a theoretical concept often used in critical scholarship, having been applied to a variety of contexts and case studies. Yet, theories that become popular run the risk of being over-used or handled incautiously. They may be invoked profusely rather than when strictly appropriate, and their significance may be asserted rather than demonstrated. In this journal, Bell and Green (2016) have raised important issues about neoliberalism as a theoretical concept in public health studies. Their overarching criticism is well taken. They observe that neoliberalism has become a term often used nonchalantly. That is, they note a tendency in some strands of scholarship to assume that neoliberalism explains everything and to reify the concept (Kipnis, 2008). Indeed, as Phelan (2007) remarks, neoliberalism is sometimes conceived in monolithic, reductive ways that neglect its complexity and diversity (Reubi, 2016). There have thus been calls for precision and nuance in the definition and study of neoliberalism (Brenner, Peck, & Theodore, 2010) in order to describe and analyse what can be referred to as ‘actually existing neoliberalism’ (Brenner & Theodore, 2002)
Nevertheless, the potential of neoliberalism as a concept in health studies should not be dismissed (Schrecker 2016a, 2016b). Indeed, while calls for nuance and specificity are important, we should still pay ‘attention to macro-scale issues of context and power relations’ (Schrecker 2016a, p. 479). As Schrecker (2016a, p. 479) reminds us, ‘[w]hatever the varied manifestations of neoliberalism, it is a coherent project the material consequences of which’ are plain to see in the form of ‘neoliberal epidemics’ (Schrecker & Bambra, 2015) or negative health consequences of neoliberal austerity programmes in southern Europe (Stuckler & Basu, 2013).
– Julien Mercille