An independent review looking into how the Health Services Authority (HSA) is governed has identified a number of failings.
The KPMG-led diagnostic assessment found decision-making roles that are unclear in practice, weak oversight of performance and risk, and a decline in internal trust.
Commissioned by the Ministry of Health, Environment and Sustainability and made public on 6 August, the review examined how the HSA is directed and held accountable rather than the quality of the clinical care it provides.
The ministry has said a separate clinical and operational review will follow. KPMG describes the work as advisory and states that it does not constitute an audit.
The assessment reflects governance practices up to December 2025 and drew on 24 stakeholder interviews, a review of 46 governance documents and two surveys completed by 686 people across Grand Cayman, Cayman Brac and Little Cayman.
It sets out 11 challenges and 47 opportunities for improvement across five governance pillars – strategic vision, governance model, performance management, collaboration and communication, and culture.
Speaking during a 6 August press conference, health minister Katherine Ebanks-Wilks said work on implementing the report’s findings had already begun, adding that the recommendations establish a framework of expectations.
“Anyone stepping into a governance role at the HSA now or in the future will be expected to meet these same standards,” she said.
“I also want to be clear that all 47 recommendations are seen [by] the ministry as a priority. None of them are being set aside. The only difference will be the timeline for implementation.”
Among the review’s conclusions is that the HSA has no formal scheme of delegation or decision-rights matrix, leaving decision-making to rest on individual interpretation of legislation and contributing to overlap between the ministry, the board, the chief executive and senior managers.
The review also found no formal organisation-wide risk management framework and no strategic risk register, and reported that board performance evaluations rely on binary yes/no self-assessments that were not readily available for review and showed no evidence of being conducted annually.
Survey responses pointed to strained relationships and low confidence. Most staff felt their views were considered only “to a limited extent” or “not at all” in decision-making (60%), and 46% found the board’s role “not very” or “not at all” clear.
Just under half of staff (48%) said the HSA manages underperformance ineffectively, with only 9% calling it “very effective”, and 51% reported limited or no comfort in raising concerns without fear of consequences.
The assessment said there had been a notable change in HSA leadership in recent years, with an organisational culture now characterised by “disengagement, criticism, and risk avoidance, rather than learning, openness, and continuous improvement”.
It added: “Meetings are described as confrontational, critical, and with limited focus on support or problem-solving. This dynamic has reduced morale, engagement, and a sense of shared purpose.”
On the patient side, only 18% said they had seen their feedback lead to change, and just 13% rated the authority “very responsive”. Two-thirds of patients (67%) said they use the HSA because their insurance requires or directs them to.
Regarding the staff figures, the appendix notes that, to be statistically robust at a 95% confidence level, the staff and external-partner survey required a minimum of 254 responses but only received 203.
The patient and caregiver survey, by contrast, cleared its own minimum of 383 responses with 483.
Throughout the report, KPMG and the minister repeatedly note that the findings pre-date a new HSA board and that changes have since begun.
The authority has restructured its board subcommittees into six bodies with updated terms of reference since the assessment was carried out.
Ebanks-Wilks framed publication as delivering on a commitment made when the review was announced.
“When we commissioned this assessment, I committed to making the findings available to the people of the Cayman Islands,” she said in a press release on 6 August. “Publishing the report in full is an important part of that commitment.”
Chief officer Tamara Ebanks, in the press release, said the work marked a shift from assessment to action: “The value of this exercise will ultimately be measured by the actions that follow it.”
The ministry says it will finalise an implementation plan within six months, establish a Governance Implementation Steering Group within three months, introduce a new chief operating officer role and review the Health Services Authority Act.
It has committed to updating the public on progress every six months.
