Dormant Committees, Crumbling Hospitals: Auditor General Exposes Decade of Neglect in Jamaica’s Public Health System

A landmark performance audit by Auditor General Pamela Monroe Ellis has found that Jamaica’s public health system was already in institutional crisis well before COVID-19 arrived — with governance bodies inactive for years, hospital beds declining, healthcare workers leaving in high numbers, and a flagship infrastructure programme whose costs have ballooned beyond what the government can currently finance. For the millions of Jamaicans who rely on public hospitals and health centres, the findings reveal a system that failed its own benchmarks quietly and without consequence for nearly a decade.

When COVID-19 reached Jamaica in March 2020, the Ministry of Health and Wellness was widely credited with mounting a visible public response. What the Auditor General’s performance audit, issued in March 2023, has now confirmed is that the institutions required to underpin that response had, in several cases, not been functioning for years — some not at all since 2013.

The audit, which examined the effectiveness of Jamaica’s institutional framework in enabling a strong and resilient national public health system, covered the period 2016 to 2021. The fieldwork, conducted between November 2021 and June 2022, assessed the Ministry of Health and Wellness against the country’s own Vision 2030 Jamaica National Development Plan, United Nations Sustainable Development Goal 3, and the World Health Organization’s International Health Regulations. What it found was a system in which legal and institutional obligations had been quietly set aside, spending had fallen well short of global benchmarks, and the infrastructure programme intended to modernise public hospitals had consumed years in planning while barely breaking ground.

At the heart of the audit’s governance findings is a simple and damning fact: the Central Health Committee, which is required to meet quarterly and serves as a key oversight body for the public health system, provided no meeting minutes, reports, or annual documentation for the entire period under review — six years, from 2016 to 2021. Not a single record of a meeting. The body charged with guiding a system that hundreds of thousands of Jamaicans depend on every year left no paper trail of its deliberations.

The IHR Committee, which exists to coordinate Jamaica’s compliance with WHO International Health Regulations and is required to meet monthly, had not convened a formal session since July 2013. That is more than eight years of inactivity by a body whose sole purpose is to prepare and protect the country against public health threats — a gap that spans the Chikungunya outbreak, the Zika crisis, and the entirety of the COVID-19 pandemic to date. The Stakeholder Advisory Group, similarly required to meet quarterly, gathered only irregularly. The audit also found a discrepancy between Jamaica’s internally assessed compliance scores and those submitted to the WHO in the State Party Self-Assessment Report — a divergence that raises questions about the accuracy of the picture Jamaica has been presenting to international bodies.

These are not procedural technicalities. They represent the collapse of the very architecture that is supposed to convert planning into action, identify gaps before emergencies strike, and hold departments accountable for delivery. When those structures stop functioning, the system is left to operate without meaningful oversight, and no one in a position of authority is formally required to notice.

The consequences of that absence show up in the implementation data. Of 36 health-related actions required under the most recent medium-term framework of the National Development Plan — covering 2018 to 2021 — only five were fully achieved. That is a 13% completion rate. A further 20 actions, representing 55% of the total, were only partially achieved, while 11 were not achieved at all. The Ministry had not completed an emergency healthcare policy, despite identifying it as a priority. For a country whose Vision 2030 plan was meant to anchor national health improvement against measurable milestones, a 13% delivery rate in a four-year period is not a minor shortfall. It is a systemic failure of implementation.

The conditions inside Jamaica’s public hospitals reflect years of underinvestment. The country averaged 1.71 hospital beds per 1,000 population across the period 2016 to 2021, falling further to 1.68 by 2021. This figure sits significantly below international standards, and the picture worsens when the practical realities are factored in. During the audit period, an average of 164 beds across the public hospital system were non-functional — out of service due to physical conditions, staffing shortfalls, or equipment failure. As of March 2022, a further 310 beds were occupied by what the audit describes as abandoned social patients: individuals who are medically cleared for discharge but who remain in hospital because there is nowhere for them to go. Together, these two groups represent a combined drag on a system that is already below capacity, limiting access for patients who need acute care.

The workforce situation compounds the pressure. The combined density of doctors and nurses in Jamaica averaged 2.71 per 1,000 population during the audit period. The WHO threshold considered necessary for adequate service delivery is 4.45 per 1,000. Jamaica was operating at roughly 60% of that standard. High workforce attrition — healthcare workers leaving the public sector, or leaving the country entirely — continued to erode that ratio throughout the period. The audit flags this as a direct threat to system resilience, and for patients in rural parishes where health centres may already be understaffed, the practical meaning of that figure is a longer wait, a further drive, or care that is simply unavailable.

The government’s response to these pressures has included a Health System Strengthening infrastructure programme, funded through an IDB loan originally approved in November 2018 at US$50 million, supplemented by an EU grant of US$11.4 million. By the time of the audit, however, the revised cost of the programme had reached US$148.5 million — nearly three times the original IDB commitment — leaving a financing gap of US$87 million that had not been resolved. Of the 13 health facilities targeted for improvement under the programme, detailed design work had been completed for only four. The audit attributes the delay to poor initial programme design, excessive time spent defining scope and budget parameters, and the disruption caused by COVID-19. The result is that facilities intended to be upgraded are waiting for designs that have not yet been completed, while the gap between what the programme costs and what has been secured in financing has grown to a level that will require substantial new commitments before construction can proceed at scale.

Behind all of this sits a persistent financing deficit. Government health expenditure as a percentage of GDP averaged 3.82% between 2015 and 2019. The Pan American Health Organization benchmark for achieving Universal Health Coverage is 6% of GDP. Jamaica’s average expenditure across the period therefore fell 2.18 percentage points short of what PAHO considers the minimum for a functional and equitable health system. In absolute terms, total government health allocations across the five financial years from 2016-17 to 2020-21 amounted to JMD$359 billion — a significant sum in nominal terms, but one that the audit places firmly in the context of what international health bodies say is needed to sustain a resilient system. Closing that gap would not simply require more money; it would require a sustained political commitment to health as a spending priority across multiple budget cycles.

Perhaps the most sobering finding in the audit is the one that concerns learning. Jamaica experienced three major public health events in the years under review: the Chikungunya outbreak, the Zika virus response, and then COVID-19. The audit found that no formal assessment or documentation of lessons learned had been conducted for either the Chikungunya or Zika responses. As of the date the report was finalised, no formal evaluation of Jamaica’s COVID-19 response had been undertaken either. In a system already operating below capacity, the failure to capture, document, and institutionalise the lessons of repeated crises means that each emergency is met with the same institutional starting point as the last. The wheel is perpetually being reinvented, at public cost and patient risk.

The Ministry of Health and Wellness broadly accepted the audit’s findings. Management acknowledged the slow pace of strategic plan implementation, the impact of COVID-19 on infrastructure timelines, and the need to finalise the emergency healthcare policy. The Ministry also committed to undertaking a formal COVID-19 Intra-Action Review with support from PAHO and the WHO, and stated that strategic actions would be revised for inclusion in the corporate plan covering 2023-24 to 2026-27. These are meaningful acknowledgements, though the audit itself provides the measure against which future progress will need to be judged: not the existence of revised plans, but the rate at which actions are actually completed.

The audit’s recommendations are direct and trackable. Dormant governance committees should be activated and their meeting obligations enforced. Post-event reviews should be conducted and their findings formally documented. The emergency healthcare policy should be finalised. The infrastructure financing gap of US$87 million needs to be closed if the Health System Strengthening programme is to be delivered. Health spending should be moved progressively toward the 6% of GDP benchmark. Information systems, currently fragmented and siloed across the Ministry’s operations, should be integrated. Healthcare worker density should be tracked systematically against the WHO threshold of 4.45 per 1,000 population.

What the audit ultimately establishes is that Jamaica’s public health system has been carrying a structural deficit — in governance, in capacity, in financing, and in institutional learning — that predates the pandemic and will not be corrected by any single budget allocation or policy announcement. The governance bodies required to manage and monitor the system were not meeting. The targets set under the country’s own national development plan were not being met. The infrastructure programme intended to address decades of underinvestment had stalled before it began. And through three successive public health crises, the system produced no formal record of what it had learned. For Jamaican taxpayers who fund this system, for patients who depend on it, and for communities whose health outcomes it is meant to improve, the audit’s findings are a documented account of what institutional neglect looks like when it accumulates over years — and a baseline against which every future claim of improvement can now be measured.

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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