Audit Reveals Jamaica’s Public Health System Left Diabetes Patients Without Basic Care While Spending $7.6 Billion

A landmark performance audit of the Ministry of Health found that Jamaica’s public health system spent years failing to adequately prevent, detect, or manage diabetes — a disease killing more Jamaicans than almost any other condition. For patients attending government health centres, basic clinical examinations were routinely skipped, monitoring tests were never ordered, and amputations mounted at a rate that placed the Caribbean among the worst in the world. The findings raise urgent questions about how billions of dollars in health spending translated into so little measurable benefit for ordinary Jamaicans.

Between 2008 and 2013, diabetes claimed 11,632 lives in Jamaica — accounting for 13.2 percent of every death recorded in the country over those five years. The disease ranked first or second among the top fifteen leading causes of death for each year reviewed. It generated nearly one million patient visits at public health centres and produced 13,637 newly diagnosed cases. By any measure, diabetes was one of the most serious threats to Jamaican lives during that period.

Yet when Auditor General Pamela Monroe Ellis and her team examined how the Ministry of Health managed the national diabetes burden between 2008/2009 and 2014/2015, they found a system profoundly ill-equipped to meet the scale of the challenge. The November 2015 performance audit documented failures at virtually every level of the public health response — from community education and early detection through to clinical monitoring, financial accountability, and institutional oversight. The cumulative picture was of a ministry that lacked the plans, the data, the staffing, and the systems necessary to protect Jamaicans from a disease that was quietly devastating families and communities across the island.

The audit began at the most basic level: public awareness. Preventing diabetes, and preventing its worst complications in those already diagnosed, depends heavily on access to clear, accurate health information. The Ministry had no Non-Communicable Disease Communication Plan. Educational materials — posters, leaflets, brochures — were absent or outdated. Planned audio and audiovisual campaigns were never produced, with financial constraints cited as the reason. The Service Level Agreements between the Ministry and the four Regional Health Authorities, which govern how health care is delivered on the ground, contained no performance indicators requiring regions to demonstrate what they had actually done to prevent diabetes in the communities they served.

The consequence of that gap was predictable. Without meaningful education and outreach, Jamaicans living with diabetes or at risk of developing it received little practical support from the public health system between clinic visits. For many patients — particularly those in rural communities or lower-income households who depend entirely on public health facilities — the government clinic represented their only point of contact with the health system. What the audit found at those clinics was alarming.

Clinical monitoring of diabetes patients, required under established medical guidelines, was largely absent. HbA1c testing — a blood test that must be performed at least once annually to assess how well a patient’s blood sugar is being controlled over time — was among the most basic obligations the system had to patients. In the Western Region, 63 percent of sampled patient files contained no record of an HbA1c test in the preceding twelve months. That same region achieved a glucose control rate of only 43 percent, falling short of its own 51 percent target. Poor glucose control, sustained over months and years, causes the damage to nerves, kidneys, eyes, and circulation that turns diabetes into a disability and a death sentence.

Foot care, another clinical requirement of fundamental importance in diabetes management, was similarly neglected. Of 219 patient files reviewed by the audit team, more than 55 percent contained no record of a foot examination. When patients themselves were surveyed, 50 percent reported that they had never received a foot examination from a health worker at all. The consequences of failing to catch early foot complications in diabetes are severe and irreversible. Between 2008 and 2010 alone, 866 amputations were performed at public hospitals. Patients who underwent amputations spent an average of up to 25 days in hospital — the longest average stay of any condition treated in the public hospital system. The Caribbean, the audit noted, already has one of the highest rates of non-traumatic lower-limb amputations in the world. Jamaica’s health system was not doing what was needed to reduce that burden.

Beyond glucose monitoring and foot care, the audit found that three-quarters of the 129 diabetes patients examined were never referred to a nutritionist or dietician, despite diet being central to managing the condition. More than 85 percent had received no referral for dental screening, eye examination, or depression assessment — each a standard component of comprehensive diabetes care. Depression, in particular, significantly worsens diabetes outcomes and is more common among people with chronic illnesses, yet it was receiving virtually no attention within the public system’s diabetes care pathways.

Institutional oversight of the quality of that care was, in practice, non-existent across most of the country. Clinical audits — structured assessments of whether clinical guidelines are being followed — are a fundamental mechanism for identifying and correcting failures in patient care before they cause serious harm. The Ministry had set itself a target of three clinical audits per year. It did not meet that target. More starkly, the South East Regional Health Authority and the Southern Regional Health Authority, between them responsible for 163 health facilities, conducted zero clinical audits during the entire period under review. The North East Regional Health Authority conducted a single clinical audit across its network of 73 health centres. A system with no internal quality review is a system with no mechanism for self-correction.

Reporting failures compounded the problem. Regional Health Authorities were required to submit annual NCD reports to the Ministry. They frequently did not, and when reports were submitted, critical data — hospital discharge rates, dialysis patient numbers — was missing. Without reliable data flowing from regions to the centre, the Ministry had no accurate picture of what was happening to diabetes patients across the country, and no evidential basis for making decisions about where resources were most needed.

The financial dimension of the audit was equally troubling. The Port of Spain Declaration, to which Jamaica is a signatory, calls for governments to establish discrete budget allocations for non-communicable diseases. No such budget line existed for diabetes within the Ministry’s financial systems. This was not a minor administrative oversight. Over the audit period, the National Health Fund spent $32.9 billion on NCD drugs. Of that total, $7.6 billion — 23 percent — went specifically to diabetes medications. That is a substantial and identifiable expenditure on a single disease. Yet the Ministry’s financial information systems were incapable of disaggregating costs by disease category. No one within the Ministry could say, with any precision, what the government was spending on managing diabetes as a distinct condition, let alone whether that spending was producing value for money.

That inability to track spending by disease made any serious evaluation of the diabetes programme impossible. The NHF had also terminated provider status for 21 of the 25 public health facilities that had previously been registered to dispense NHF-covered medications, citing inactivity. For patients who depended on those facilities to access subsidised diabetes drugs, the practical effect was a loss of access to medicines they needed to stay alive.

The audit identified several root causes for these compounding failures. Financial constraints were cited repeatedly, but the report also pointed to a structural absence of accountability mechanisms, insufficient staffing — NCD Coordinators existed in only one of the four regions — and supply chain failures including reagent shortages that prevented laboratories from processing tests, and equipment failures that went unaddressed. Underlying all of these was what the Auditor General identified as a failure to strategically reorient Jamaica’s public health system toward a chronic care model, one designed to support patients living with long-term conditions rather than responding episodically to acute illness.

The Auditor General’s recommendations were direct. The Ministry was urged to build meaningful public health education programmes, using cost-effective media partnerships to reach Jamaicans in their communities. Strengthening ministerial monitoring — to verify that clinical protocols were being followed at health centres, and that regional reporting was complete and accurate — was identified as an urgent priority. On financial governance, the audit called for implementing information systems that could track disease-specific costs, so that decision-makers could understand what the government was spending on diabetes and whether it was having any effect.

The Ministry of Health, in its formal response to the audit, acknowledged the findings and reported that corrective measures were already underway as of September 2015. These included adding health promotion performance indicators to the Service Level Agreements with Regional Health Authorities, and redesigning educational materials for distribution through public facilities. Whether those commitments translated into lasting change would depend on the monitoring mechanisms the audit had identified as almost entirely absent.

The audit’s deeper significance lies in what it reveals about the relationship between governance and public health outcomes. Thousands of Jamaicans died from diabetes during the years under review. Hundreds lost limbs. Many more sustained damage to their kidneys and eyesight that will affect them for the rest of their lives. The audit cannot establish a direct causal chain between each administrative failure and each individual death. But it establishes clearly that a system which conducted no clinical audits, tracked no disease-specific spending, failed to examine patients’ feet, and produced no communication strategy was not a system doing what it was funded to do.

For Jamaican taxpayers and the communities they live in, the audit of the Ministry of Health’s diabetes management programme is a case study in what happens when public money flows into a system without the accountability structures needed to translate funding into results. The recommendations before the Ministry in 2015 — better data, stronger oversight, cost tracking by disease, and meaningful engagement with patients and communities — remain the conditions under which any serious improvement in diabetes outcomes is possible. The audit made plain that those conditions did not yet exist. Building them is not merely an administrative exercise. It is a matter of whether Jamaica’s public health system serves the Jamaicans it exists to protect.

Jamaica Accountability Watch is an independent editorial series by Jamaica Homes News examining what government audit reports reveal about the management of public money. Source: Auditor General’s Department of Jamaica.

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