The Government lacks the resources and information required to manage the health care system effectively, says Sue Winspear, Auditor General of the Cayman Islands, in her performance audit report issued today. The report, “Ensuring Quality Health Care and a Healthy Population”, assesses how effectively the Government oversees and regulates the health care system.

“Without the resources and information needed to effectively manage the health care system, the Government cannot provide assurance to legislators and the public that it delivers high quality health care and achieves value for money,” said Ms. Winspear.

The audit also examined how the Government promotes and monitors compliance with health-related laws and regulations and whether it provides good information to the public about how well health care facilities are meeting their obligations. Finally, the auditors assessed whether the health care system achieves outcomes that are consistent with the Government’s performance expectations and with relevant international standards.

While the audit found that health outcomes in the Cayman Islands appear to compare well with other jurisdictions, the information presented may conceal important differences between the health of Caymanian and expatriate populations.

“We found that the Government still has much to do to implement its own 2012 strategic plan for improving health care. Having spent so much effort to identify what it needed to do, the Government should have made a better effort to plan for and implement the improvements,” said the Auditor General.

Issued with the audit report was a public interest report, “Cayman Islands Health System.” Ms. Winspear explained that her Office wrote that report because there was very little public information accessible to legislators that described how the health system works and how Government manages the approximately $138 million of public funds used to provide accessible quality health care.

“When legislators are making policy decisions that affect approximately 18% of total government expenditure, I believe those decisions should be made with the full understanding of how they could impact the health of residents of the Cayman Islands,”said Ms. Winspear.

More information about these reports can be obtained by contacting the Office of the Auditor General at (345) 244-3201. The reports are available at www.auditorgeneral.gov.ky.

EXECUTIVE SUMMARY [From Ensuring Quality Health Care and a Healthy Population”]
Health spending in the Cayman Islands accounts for nearly 10 per cent of Gross Domestic Product, split almost evenly between the public and private sectors. The Government’s health-related expenditures of $138 million accounted for more than 18 per cent of total government spending in 2015-2016. The large amounts of money involved, and the need for residents to have ready access to affordable, high-quality health care, underline the importance of providing the Legislative Assembly as well as providing residents with assurance that value for money is being achieved. This audit examined the Government’s oversight and regulation of the Cayman Islands health system.

The Ministry of Health (the Ministry) is responsible for the regulation and oversight of all health services. Its main objective is to ensure a healthy population and quality health care to the people of the Cayman Islands. Accordingly, the objective of this audit was to determine whether the Government’s roles and responsibilities in achieving these aims are defined and communicated clearly and managed effectively. The audit examined the manner in which the Government has established and communicated its roles, responsibilities, policies, and strategies in the health system; its authority and capacity to deliver on its related accountabilities; its means for promoting and monitoring compliance with the legislative framework; the performance management and reporting framework it has implemented; and, finally, the extent to which the results and outcomes of the health system are consistent with any performance expectations established by the Government and with relevant international standards.

The audit found that the Government’s roles and responsibilities are mostly set out and communicated through the legislative framework it has put in place. Despite some gaps, the health system’s legislative framework provides the Government with a firm basis for the authority required to execute its roles and responsibilities.

A major leadership initiative of the Government involved the 2012 development of The National Health Policy and Strategic Plan for the Cayman Islands 2012-2017 (NHPP) to serve as “an instrument for providing direction and coherence to the many stakeholders involved…” However, we found that the Government had subsequently failed to develop the operational plan that was required to implement the NHPP.

More generally, the audit found that the Government’s ability to execute its health-related roles and responsibilities is impaired by weaknesses in two-way communication with its private sector partners and by shortages in capacity. There are resourcing shortages at the Ministry level (where they were identified as one of the major factors leading to delays in implementing the NHPP), within the Department of Health Regulatory Services (where the enforcement of compliance with the Health Insurance Law and Regulations has suffered despite innovative initiatives that have sought to compensate for a shortage of staff), and within the Health Services Authority (HSA).

Ensuring Quality Health Care and a Healthy Population
The audit identified weaknesses in the Health Practice Commission’s practices and policies for registering and licensing health care practitioners and inspecting and certifying health care facilities, exposing patients to unnecessary risks. Monthly reports from the Department of Health Regulatory Services do not provide the Ministry with the information it would need to systematically track and analyse the extent of compliance with key requirements of the health practice and Health Insurance Law and Regulations, information the Ministry could use to help guide decisions and take corrective action.

The Government has not put in place a performance management and reporting framework for the health system. It has not established and communicated realistic performance expectations or reporting systems to obtain regular and reliable performance information that it could use to inform decisions aimed at improving the quality of care, delivering better health outcomes, and achieving better value for money. In other words, without a performance management and reporting framework, government officials and Members of the Legislative Assembly cannot make properly informed decisions about how to use health care resources or how to deliver health care in the Cayman Islands.

Even without a performance management and reporting framework, however, some performance- related information is available from a variety of sources. Using available data, the audit compared the performance of the Cayman Islands health system with relevant international standards and experience. The audit identified opportunities in the Cayman Islands to improve the quality of care. We also noted that the CayHealth programme, launched on a pilot basis in 2010, is an example of leading practice in managing chronic disease, although it is limited to a relatively small segment of the population.

Health outcomes in the Cayman Islands appear to compare well with health outcomes in other jurisdictions. However, the Cayman Islands population includes a high proportion of expatriate residents (non-Caymanians) who mostly live in the Cayman Islands during the healthiest years of their lives; they also have to undergo medical examinations before being granted work permits and resident status. This means that a portion of the health statistics available, which reflect averages for the whole population and across all age groups, may conceal important information about the relative health status of Caymanian and non-Caymanian residents. Data from the 2010 census about the incidence of some diagnosed illnesses shows, for example, that the incidence of heart conditions is nearly six times greater among the Caymanian population, and that of diabetes is three times higher.

Available data shows that there are more physicians, dentists and hospital beds per capita in the Cayman Islands than in Canada, the United States, the United Kingdom, the Bahamas or Barbados. But the number of nurses per capita in the Cayman Islands, while higher than in either the Bahamas or Barbados, is much lower than in the United States, Canada or the United Kingdom. Relatively little information is available on the extent to which patients are satisfied with their encounters with the health system. Within the public sector, the HSA is actively seeking reliable information on patient satisfaction with its services.

Ensuring Quality Health Care and a Healthy Population
We concluded that there are shortcomings in the Government’s management of some of its roles and responsibilities, to the extent that they may compromise the achievement of its stated aims of ensuring quality health care for the people of the Cayman Islands and a healthy population. The Government does not have the resources or the information required to manage the health system effectively, and neither the Legislative Assembly nor the public can be confident that high quality health care is being delivered, or that value for money is being achieved.
The assistance and cooperation we received from government and private sector officials and health care practitioners in all phases of the audit is gratefully acknowledged. Without their help, the audit could not have been completed.