Marketisation and regional planning in neoliberal public services: Evidence from French hospitals

Marxist scholarship has documented the implications of ‘neoliberal’ reforms to public services. This scholarship often considers these reforms as class projects which have disciplined working populations and created new opportunities for capitalist profit-making. But in this article, we shift emphasis to the internal dysfunction that shapes states’ pursuit of market-oriented policy agendas. We place closer focus on the specific levers through which marketising reforms are implemented, noting the conflicting pressures they unleash, and the cracks this may open through which a more democratic agenda can be advanced. Taking the French hospital sector as an example, we show how attempts to expand and intensify competition in public services have coincided with attempts to decentralise governance to the regional level. While ostensibly part of the same ‘reforming’ policy agenda, marketising policies have a strongly centralising logic which has in practice undermined efforts to develop meaningful regional planning. These institutional tensions have catalysed new political currents, as the relationship between public authorities and private sector actors has become more overtly conflictual. We argue that Marxist theorists of the state need to pay closer attention to the often dysfunctional relationship between different branches of the state, and that in the context of neoliberal public service reform, the tensions between central and regional states are particularly salient. We conclude that opponents of the marketisation of public services need to pay attention to the contested and ambiguous nature of ‘decentralisation’: while it is often a rhetorical cover for marketisation, there are opportunities for the left in demanding more meaningful and authentic forms of regional planning.