Shut Down Ad-din Hospital? Not So Fast.

The recent closure of Addin Hospital of Bangladesh illustrates how regulators in Bangladesh sometimes impose extreme sanctions without considering proportional alternatives, resulting in severe unintended consequences. 

On June 11, the decision by the Directorate General of Health Services (DGHS) to revoke the license of Ad-din Medical College Hospital in Moghbazar, Dhaka, is a textbook case of a well-intentioned policy causing substantial negative externality -- a spillover effect that affected people negatively who were not involved in the accident on May 27.

The shutdown has been imposed due to the newborn deaths in a post-operative ward due to severe air-conditioning and ventilation failure. Although the DGHS’s urge to punish negligence is justified, the chosen method is questionable from a theoretical perspective on public policy.

By looking at a complex crisis through a single lens, absolute closure, policymakers completely ignored many other dimensions of policy analysis as taught in the textbooks.

Overnight, hundreds of low-income patients, dozens of babies in the NICU, and over 400 medical students, including foreign students, were thrown into an uncertain future. 

In this article, I have analyzed the revocation of the Ad-din Hospital’s license from a public policy perspective.

Such a complete shutdown not only punishes the people involved in negligence that caused the death of newborns, but it also affects highly expensive healthcare assets, thousands of patients, hundreds of medical students and employees of the hospital and allied services. 

As per another theory of public policy, the Policy Externalities Framework states that a policy implemented in one room will always create "spillover effects" in another. Thus, good policymaking requires mapping out these side effects before pulling the trigger.

The rights-based theory of development holds that the state should consider not only the rights of victims of the accident but also those of innocents not involved in it.

In the case of Ad Din Hospital closures, the decision created at least two severe negative spillovers that policymakers should have considered. 

Firstly, the crisis faced by the admitted patients was so severe that it was not possible for any authority to manage. Forcing the sudden transfer of critical, oxygen-dependent newborns to already overcrowded public hospitals accelerates the safety risk rather than eliminating it.

Secondly, the hospital is a medical college hospital, which is part and parcel of an educational ecosystem. Shutting it down instantly freezes the clinical training of 400 to 500 future doctors and nurses, creating an unnecessary educational crisis.

In public policy literature, Instrument Choice Theory (IC Theory) states that regulators have a whole "toolbox" of options to solve a problem -- ranging from soft warnings and heavy fines to partial closures and complete shutdowns.

The golden rule, as per the theory, is to contextualize the policy. Considering the IC Theory, DGHS could have gradually introduced alternatives in the above case.

The authority could have sealed off the faulty neonatal ward entirely, imposed an exemplary financial penalty, and mandated immediate engineering repair of the ventilation system. However, by revoking the entire hospital's license, the policymakers chose the most extreme option available.

The best policy option that could be applied in the case of Ad-din hospital can be explained by Ayres and Braithwaite’s Pyramidal Enforcement Structure. 

Like IC Theory, this theory argues that regulators should adopt a pyramidal enforcement structure, in which the base (most used) includes options for persuasion, warnings, and negotiated compliance.

The middle part of the pyramid represents civil penalties, corrective action orders, and financial sanctions. Finally, the apex (least used) is license revocation and criminal prosecution. The DGHS fired the "nuclear option" (the apex) without exercising the lower tiers of the policy pyramid.

According to this theory, regulators must accelerate gradually, giving the regulated organization chances to remediate. By jumping straight to revocation, the DGHS ignored the "tit-for-tat" logic of responsive regulation.

Furthermore, the theory suggests that severe penalties should be reserved for deliberately non-compliant or law-breaking actors. Ad-din had no history of major violations of the license conditions, yet it suffered a catastrophic infrastructure failure.

The policy analysis lens also captures that the regulator did not issue any directives for the admitted patients, medical students and other employees of Ad-din hospital. Even if the apex decision was inevitable for the regulators, there should have been an adjustment period for the immediate sufferers under certain guidelines.

The revocation of Ad-din Hospital can be an exceptional case in Bangladesh’s policy landscape. But if such cases continue to occur, the country's governance and public policy framework will remain far from international standards.

The policy advisors, civil society think tanks and public policy researchers need to rethink the policy-formulation capacity and associated limitations of policymakers in Bangladesh.

Zobayer Ahmed is a policy analyst and is currently working as an associate professor at the Bangladesh Institute of Governance and Management (BIGM).