- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
The Cayman Islands comprises three islands: Grand Cayman, Cayman Brac, and Little Cayman. They are located in the western Caribbean Sea, approximately 240 km south of Cuba and 270 km northwest of Jamaica. Grand Cayman is the largest and most populated island; it covers 200 km2 and is approximately 35 km long with an average width of 6 km. George Town, the capital, is on Grand Cayman. There are no rivers on any of the islands and the coasts are largely protected by offshore reefs. Given its small size, the Cayman Islands’ tropical climate is strongly influenced by the sea and prevailing winds.
Cayman is one of the six self-governed United Kingdom Overseas Territories (UKOTs) in the Caribbean; the Queen of the United Kingdom is Head of State and is represented by the Governor. The Governor is responsible for foreign affairs, defense, internal security, and the police. The present Constitution, which came into effect in 2009, establishes the appointment of the Premier, Deputy Premier, Deputy Governor (who must be Caymanian), and Minister of Finance, and provides for an 18-member Legislative Assembly. The Cabinet is composed of the Premier, six other Ministers, and two nonvoting ex-officio members and is responsible for the formulation and implementation of policy as it relates to every aspect of government.
The total resident population of Cayman Islands in 2015 was 60,413; 56.7% were Caymanian and 43.3% were non-Caymanian (). Figure 1 shows the structure of the population by age group and sex, estimated for 2015. Of the 26,780 households in Cayman, 95.7% are located on Grand Cayman. In 2015, the crude birth rate was 11.0 live births per 1,000 population.
Figure 1. Population structure, by age and sex, Cayman Islands, 1991 and 2015
The Cayman Islands population increased by 12.8% between 1991 and 2015. In 1991, the population structure had an expansive pyramid shape for the age groups over 35 years, while the population under age 25 showed stationary growth. By 2015, the expansive pyramid shape had moved to age groups over 50 years. The population under that age had stationary growth, especially in age groups under 30 years, in relation to decreases in fertility and mortality in the last decades.
Source: Pan American Health Organization, based on the United States Census Bureau International Database, August 2016.
Cayman Islands’ main industries are financial services, tourism, and real estate sales and development (). The economy has experienced slow but steady growth since the 2009 recession through policy interventions such as reduced import duties, lower business licensing fees, development concessions, extended support to small businesses, and other initiatives geared toward achieving greater economic diversification and increased employment opportunities ().
In 2015, the gross domestic product (GDP) grew an estimated 2.0%, which was lower than the 2.4% growth in 2014, but exceeded the average growth of 1.6% between 2010 and 2014. The economic growth was broad-based, as all sectors expanded except the hotel and restaurant sector, which declined by 0.7% in 2015 compared to 4.9% growth in 2014. This was mainly due to a slowdown in the growth of stay-over arrivals (). Nominal GDP per capita income in 2015 was US$ 57,298, lower relative to the US$ 59,587 estimated for 2014. The inflation rate was 1.3% in 2014, but there was deflation (–2.3%) in 2015, mainly as a result of lower global oil prices and a continued downtrend in housing rentals. The United States continues to be the dominant trading partner of the Cayman Islands, accounting for 85.3% of total imports ().
There are no direct taxes in the Cayman Islands and the government raises its revenue from fees and duties. Against a background of economic recovery, improvements in labor market indicators continued in 2015 with a further reduction in unemployment. In 2015 the total employment rate increased by 4% to 39,138 jobs (). The unemployment rate among Caymanians declined from 7.9% in 2014 to 6.2% in 2015 ().
The government provides free education for Caymanian children at primary and secondary schools. As of 2014, the mean years of schooling was 13.4, with no difference between men and women ().
The Cayman Islands has a Human Rights Commission, whose mission is to lead in promoting, protecting, and preserving human rights in the Cayman Islands. This is accomplished by: promoting the integration of human rights values into everyday life; encouraging government accountability to national and international human rights standards; embracing the Cayman Islands Bill of Rights, Freedoms and Responsibilities and the principles of democracy; and empowering all persons to understand and exercise their rights.
In 2011, Cayman Islands passed the Gender Equality Law which prohibits discrimination in employment and related matters and serves as local “enabling legislation” to uphold the principles of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). In 2016, the UK officially extended CEDAW to the Cayman Islands.
The National Health Policy and Strategic Plan outlines the vision, values, strategic directions, and objectives with regard to health and the health system. The vision is “Health and Well-being for All in the Cayman Islands” ().
A Cancer Registry was established in 2010, but it is currently voluntary. A Cancer Registry Bill, introduced in 2015, was released for public consultation but has not progressed due to concerns with confidentiality.
The Mental Health Law was revised in 2013 to provide better care for persons with serious mental illnesses or mental impairment (). The Mental Health Commission was also established in 2013 to provide oversight on matters relating to mental health and well-being, which includes protecting the rights of patients, and providing support to and advocating for persons living with mental illness, and their families, as well as general education about the Mental Health Legislation (). The Ministry of Health is in the process of finalizing a Mental Health Policy.
In keeping with the Framework Convention on Tobacco Control (FCTC) and in accordance with the Tobacco Law, passed in 2008, and Tobacco Regulations of 2010, public places are smoke-free. This comprehensive legislation governs the sale, promotion, and use of tobacco in the Cayman Islands.
The United Kingdom’s Foreign and Commonwealth Office (FCO) represents the needs and concerns of the Overseas Territories at regional and international meetings, and fulfills international responsibilities related to such instruments as the International Health Regulations (IHR), the FCTC, and reporting on the Sustainable Development Goals (SDGs) ().
The Health System
The Ministry of Health has the primary responsibility for developing health policies and programs, and providing health services through its various departments and authorities . The Health Services Authority (HSA) is the sole provider of public health care services at primary, secondary, and tertiary levels of service. Included in this network of services are the 124-bed Cayman Islands Hospital on Grand Cayman, the 18-bed Faith Hospital on Cayman Brac, primary health care and public health services delivered through Faith Hospital in Cayman Brac, five district health clinics in Grand Cayman, one district health clinic in Little Cayman, and school health clinics. The Cayman Islands Hospital and Faith Hospital offer inpatient and outpatient services, including some specialist services.
Dental services are delivered on-site at the Cayman Islands Hospital and Faith Hospital, as well as through the schools and district clinics in Grand Cayman and Little Cayman. Ophthalmology services are also delivered on-site at the Cayman Islands Hospital and through visiting specialists on Cayman Brac. Other departments that form part of the public health service are the Department of Environmental Health, and the Mosquito Research and Control Unit.
There are two private hospitals in the Cayman Islands: the CTMH Doctors Hospital (established in 2000 as the Chrissie Tomlinson Memorial Hospital) and Health City Cayman Islands. CTMH Doctors Hospital is a private, for-profit 18-bed medical/surgical hospital specializing in surgical care (). The hospital offers diagnostic and imaging capabilities, family practice, and pediatric medical care. Health City Cayman Islands opened on Grand Cayman in February 2014 (). It is a tertiary care hospital specializing in chronic and acute cardiac, orthopedic, bariatric, neurological, and pediatric cases.
Leading Health Challenges
Critical Health Problems
In June 2014, the first case of chikungunya fever was confirmed in the Cayman Islands; by the end of 2014, 44 cases had been confirmed (28 imported, 16 local). There were six cases detected in 2015, and all were imported. As of November 2016, 30 Zika fever cases had been confirmed; 20 cases were local and 10 were imported.
The Mosquito Research and Control Unit (MRCU) was established in 1965 to protect residents and visitors from mosquito-borne disease. In July 2016, the Unit released genetically modified mosquitoes in the West Bay area of Grand Cayman. Standard mosquito control measures will continue during the project, and if the project is successful at reducing the number of Aedes aegypti mosquitoes, which are responsible for spreading Zika, dengue, and chikungunya, consideration will be given to releasing the mosquitoes across Grand Cayman ().
In order to determine the burden of chronic, noncommunicable diseases (NCDs) in the Cayman Islands, the Ministry of Health conducted the “Healthy Nation Survey” of 25–64-year-olds in 2012, using the STEPS survey instrument to identify risk factors for NCDs (). The major risk factors identified in the survey were use of tobacco, daily consumption of less than five servings of fruit and vegetables, overweight, raised blood pressure, and low level of physical activity. Of those surveyed, 42.9% reported having three or more of these risk factors, and of this group, 39.2% were in the 25–44-year age group. According to the body mass index (BMI) classification, 36.6% of respondents were classified as obese and 70.6% were classified as overweight. Of those surveyed, 15.8% had raised blood pressure (= 140 mmHg) and were not on medication for this condition. Approximately 15% of the population smokes tobacco. Men (20.7%) were two times more likely than women (9%) to smoke. The percentage of the population who reported currently using alcohol (had drunk alcohol in the 30 days prior to the survey) was 51.5%. The proportion of men (63.0%) who reported currently drinking was greater than that of women, (39.4%). The highest percentage of current drinkers was reported in the 25-34-year-olds, at 59.7%, with no significant differences between men and women. The survey results pointed to low levels of physical activity; 34% were classified as having low levels of physical activity. More men were active than women and younger persons were more active than older persons.
An assessment of the mental health system in the Cayman Islands was conducted in 2014 using the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS). The data collected from six outpatient facilities offering mental health services indicated that almost 4,000 patients were treated in 2013; 9% of visits were by children and adolescents 17 years of age or younger. The majority of the patients were diagnosed with schizophrenia, mood (affective) disorders, and neurotic, stress-related disorders (). The main challenges to providing mental health care are the lack of a long-term residential mental health facility and a shortage of outpatient services for children and youth.
In 2015, the health workforce of the Cayman Islands consisted of 330 doctors (5.5 per 1,000 population), 442 nurses (7.3 per 1,000), and 48 dentists (0.8 per 1,000) (see Table 1). A total of 494 other health professionals (8.2 per 1,000) were registered and licensed to practice on the islands and included physical and occupational therapists, psychologists, pharmacists, radiographers, medical technologists, dental assistants, forensic scientists, emergency medical technicians, etc. The private sector employed 56% of medical professionals. The expansion of medical tourism resulted in an increase of health workers in the past four years.
Table 1. Number of health professionals by facility and profession, and density of health professionals,a Cayman Islands, 2011–2015.
|Number of health professionals by facility|
|Cayman Islands Hospital, Grand Cayman (government-supported facility)||424||424||436||455||537|
|Faith Hospital, Cayman Brac (government-supported facility)||52||39||39||38||43|
|Private practice (Grand Cayman, Cayman Brac, and Little Brac)||459||373||409||635||732|
|Total (government and private)||935||836||884||1,170||1,312|
|No. health professionals by category|
|Ratio of health professionals (per 1,000 population)|
|All health professionals||16.8||14.7||15.9||20.1||21.7|
a Ratio per 1,000 population.
b Other professionals include: physiotherapists, occupational therapists, psychologists, pharmacists, radiographers, medical technologists, dental auxiliaries and hygienists, nutritionists, genetic counselors, health promotion officers, forensic scientists, emergency medical technicians, paramedics, etc. The data exclude all visiting and locum tenens professionals.
Source: Cayman Islands, Ministry of Finance and Economic Development, Economics and Statistics Office, Compendium of Statistics, 2015 (George Town); Table 4.02a.
The nursing school at the University College of the Cayman Islands (UCCI) offers a bachelor of science degree in nursing; nurses are registered through the Nursing Council of Jamaica ().
Health Knowledge, Technology, and Information
The Health Services Authority has a health information system in place. It is designed to transmit and store medical data for the two public hospitals and six regional clinics. The system has modules for clinical, administrative, and financial information and patient records. The private sector health care providers use health information systems that are not integrated with the public system. HSA has developed a patient portal that will be expanded to provide patients with access to diagnostic information and appointment scheduling ().
At present there is limited use of information and communication technology and social media for collaboration between the health sector and other sectors and departments or for increasing technical cooperation.
The Environment and Human Security
The Cayman Islands’ low-lying islands are particularly vulnerable to the rise in sea level. The islands are also located in “hurricane alley,” which heightens the risk of and vulnerability to more intense hurricanes created by higher sea surface temperatures. No significant environmental events were recorded during the reporting period. The Cayman Islands has adopted a comprehensive plan of action to combat damaging effects of climate change. The Cayman Islands have drafted a Climate Change Policy designed to achieve a low carbon climate-resilient economy. The policy refers to the vulnerability of the Caribbean Islands for natural disasters induced by climate change ().
The traditional sources of water supply through private wells and/or catchment in cisterns have been replaced by piped water on Grand Cayman and Cayman Brac. This service is provided by the Water Authority and the Consolidated Water Company, both of which provide desalinated water. There are no Water Authority operations in Little Cayman, but a number of small desalination plants serve individual properties and developments. As of 2015, 97% of households had access to improved water, 91% of which had piped water and 6% of which received water through other improved methods. The coverage for improved sanitation was 96% ().
Three landfills operate in Cayman Islands. For 2011, the total waste managed was approximately 69,011 tons (). The government has developed a National Solid Waste Management Strategy that uses an integrated solid waste management system to improve the sustainability of waste management practices and make increased use of waste as a resource ().
The number of road traffic accidents increased from 968 in 2014 to 1,068 in 2015. Of the 1,068 accidents, 13 involved fatalities, 35 resulted in serious injuries, and 270 in minor injuries.
In 2015, of the 3,685 crimes reported, 47% were property crimes (theft and burglary) and 20% were related to assault, including rape and other sexual offenses. Eight attempted murders and three murders were reported in 2015 ().
The Cayman Islands has a small agricultural sector comprising 302 registered farmers who in 2015 cultivated 11.25% of the territory’s area. Most foods are imported from North America, Jamaica, and the UK ().
Monitoring the Health System’s Organization, Provision of Care, and Performance
Cayman Islands is committed to having a health system that ensures access to the highest-quality care at costs that are affordable and sustainable for all residents. However, providing and sustaining affordable and accessible health services continues to be a challenge in the face of rising health care costs and budgetary constraints.
In 2015, total expenditures on health care by the government and private sector were approximately US$ 328 million, representing 9.74% of total GDP. Public funding accounted for approximately 51% of health expenditures and private insurance and out-of-pocket payments accounted for 49%. Public health care expenditure as a percentage of the government’s total spending increased from 23% in 2011 to over 25% in 2015 ().
The Health Insurance Law, which was revised in 2013, requires every resident of the Cayman Islands to have health insurance coverage. Employers are required to provide a Standard Health Insurance Contract (SHIC) plan that has the minimum, required health benefits for employees and any dependents who reside in the Cayman Islands. Employees contribute a maximum of 50% of the cost of their plan. While benefits provided in the government-regulated SHIC form the basis of all health insurance plans, most employers offer higher than the mandated coverage (). Self-employed persons must provide for their own and their dependents’ health insurance. Health insurance coverage must be obtained through one of the nine approved health insurance providers.
The Cayman Islands National Insurance Company (CINICO), a government-owned insurance company, was established in 2004 to provide health insurance coverage to civil servants, pensioners, seafarers, veterans, and their dependents (). CINICO also provides coverage to the indigent, elderly, and persons who are unable to obtain coverage through private insurers. It also provides health insurance coverage for selected statutory authorities and government entities.
Although all residents are required to have health insurance coverage, health care financing remains a challenge as health costs continue to increase. There is a need to address the escalating costs and arrive at a sustainable financing model to ensure the future viability of the health care service delivery system.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
No maternal deaths were reported in 2015 (). Antenatal care coverage with skilled birth attendants (4+ visits) was 98.8% and hospital births 99.7% in 2015 ().
Health of Adolescents
The Cayman Islands Adolescent Health and Sexuality Survey () was conducted among 15–19-year-olds in 2012 as part of a regional project to strengthen HIV prevention programs for adolescents. Approximately 40% of those surveyed reported they had more than one sex partner over the past year. Three-quarters of those who had ever had sex had their first sexual experience before they were 16, the legal age of consent, and a higher percentage of boys than girls had sex before the age of 15. Approximately 10% of respondents said that they had been sexually abused by a member of their family or another person; the prevalence of sexual abuse was six times higher among females (18.6%) than males (3.1%). Additionally, of those who ever had sex, 4.9% stated that they were forced or threatened into sex the first time (raped) and 8.1% said that they were “sort of” forced or threatened. More than half (55.6%) reported they had been depressed. The adolescents generally reported they received family care, support, and encouragement. Marijuana had been used by 35.1% of respondents, and 6.8% of respondents reported having used psychoactive drugs. Over half of participants (53.3%) had drunk alcohol in the past 30 days.
In 2015, 170 deaths were reported in Cayman Islands, for a crude death rate of 2.9 deaths per 1,000 population. Of those deaths, 64 were male and 106 female, with the highest number (42) in the 80–89-year age group. Diseases of the circulatory system caused 30% of all deaths in 2014, followed by malignant neoplasms (28%) (see Table 2). Table 3 shows the infant mortality rates between 2002 and 2015.
Table 2. Leading causes of death, by sex, Cayman Islands, 2014.
|Total deaths||Male deaths||Female deaths|
|Cause of death||No.||Percentage||No.||Percentage||No.||Percentage|
|Diseases of the circulatory system||51||30%||22||27%||29||33%|
|Diseases of the respiratory system||17||10%||7||9%||10||11%|
|External causes (homicide, motor vehicle accident, drowning , other)||16||9%||14||17%||2||2%|
|Endocrine, nutritional, and metabolic diseases||12||7%||3||4%||9||10%|
|Infectious and parasitic diseases||5||3%||2||2%||3||3%|
|Diseases of the genitourinary system||5||3%||1||1%||4||4%|
|Diseases of the nervous system||4||2%||1||1%||3||3%|
|Symptoms, signs and abnormal clinical and laboratory findings||4||2%||1||1%||3||3%|
|Conditions originating in the perinatal period||2||1%||1||1%||1||1%|
|Total deaths, all causes||170||100%||81||100%||89||100%|
Source: Cayman Islands, Ministry of Finance and Economic Development, Economics and Statistics Office, Compendium of Statistics, 2015 (George Town); Table 4.04a.
Table 3. Infant mortality rate in Cayman Islands, 2002–2015.
|Year||Infant mortality rate (per 1,000 live births)a||Neonatal mortality rate (per 1,000 live births)b||Perinatal mortality rate (per 1,000 live births)c|
a Infant mortality rate: the number of deaths of children under one year of age, expressed per 1,000 live births.
b Neonatal mortality rate: the number of deaths of children under 28 days of age, expressed per 1,000 live births.
c Perinatal mortality rate: the number of deaths of infants after 22 weeks of gestation and before 7 days of life, expressed per 1,000 live births.
Source: Cayman Islands, Health Services Administration.
Since the first case of AIDS was reported in the Cayman Islands in 1985, 145 HIV infections have been reported, 74 persons have developed AIDS, and 46 have died as of November 2014. Currently there were 67 persons living with HIV in the Cayman Islands. Cayman is in the process of verifying and documenting the elimination of mother-to-child transmission of HIV and congenital syphilis; no cases of either infection have been reported since 2004. Cayman Islands follows the WHO guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.
In 2015, 61 cases of chlamydia, 5 cases of gonorrhea, 14 cases of herpes, 14 cases of syphilis, and 9 cases of trichomonas had been reported. There were no cases reported for hepatitis B in 2015.
Other communicable diseases reported included 34 cases of chicken pox and 287 cases of conjunctivitis in 2015. In 2014, 5,818 cases of influenza-like illnesses were reported (), and 5,955 cases were reported in 2015. Childhood vaccination is provided free of charge to residents.
No cases of tuberculosis were reported in 2014 (), but there were seven cases in 2015 (one local and six imported). In 2013, there were two imported cases of malaria; no cases were detected in 2014, and there were five imported cases in 2015.
In 2017, the Ministry of Health will commence work on reviewing the National Health Policy and Strategic Plan for 2012–2017, with a view to developing action plans and subsequent implementation. The Mental Health Policy will be finalized in 2017; it will identify priority areas for action in an effort to improve the health and well-being of persons suffering from mental illness. It is anticipated that in the third quarter of 2017, work will commence on the construction of a long-term residential mental health facility to accommodate chronically ill patients The Cayman Islands Health Services Authority Strategic Plan 2010-2018 has a strong focus on access to quality health care, including enhancing access to primary health care and strengthening community health through a network of lay-persons. It also seeks collaboration with various partners to actively involve the population in addressing NCDs ().
1. Economics and Statistics Office (Cayman Islands). The Cayman Islands’ compendium of statistics 2015. George Town: ESO; 2016. Available from: http://www.eso.ky/UserFiles/right_page_docums/files/uploads/the_cayman_islands_compendium_of_statist-1.pdf.
2. Government of the Cayman Islands. Cayman Islands economy [Internet]. George Town: GOCI; 2016. Available from: http://www.gov.ky/portal/page/portal/cighome/cayman/theeconomy/economy.
3. Ministry of Finance & Economic Development (Cayman Islands). 2016/2017 Strategic Policy Statement – Address by the Hon Marco Archer [Internet]. George Town: MFED; 2016. Available from: http://www.gov.ky/portal/page/portal/pfehome/publications/2016-17-sps-address-by-hon-marco-archer.
4. Economics and Statistics Office (Cayman Islands). Cayman’s economy sustained growth in 2015 [news release]. 7 Jul. George Town: ESO; 2016. Available from: http://news.eso.ky/caymans-economy-sustained-growth-in-2015_13842.html.
5. Economics and Statistics Office (Cayman Islands). The Cayman Islands’ foreign trade statistics report 2015. George Town: ESO; 2016. Available from: http://www.eso.ky/UserFiles/page_docums/files/uploads/cn_-_the_cayman_islands_annual_foreign_t.pdf Accessed August 2016.
6. Economics and Statistics Office (Cayman Islands). The Cayman Islands’ annual economic report 2015. George Town: ESO; 2016. Available from: http://www.eso.ky/UserFiles/page_docums/files/uploads/the_cayman_islands__annual_economic_repo-2.pdf Accessed September 2016.
7. Pan American Health Organization. Health situation in the Americas: core indicators 2016. Washington, D.C.: PAHO; 2016. Available from: http://iris.paho.org/xmlui/handle/123456789/31289.
8. Ministry of Health, Environment, Youth, Sports and Culture (Cayman Islands). National Health Policy and Strategic Plan for the Cayman Islands, 2012-2017. George Town: MHEYSC; 2013. Available from: http://www.ministryofhealth.gov.ky/sites/default/files/MHEYSC_NATIONAL_HEALTH_POLICY.pdf.
9. Ministry of Health, Environment, Youth, Sports and Culture (Cayman Islands). Mental Health Law, 2013 (Law 10 of 2913). 17 May. GE41/2013 s4. George Town: MHEYSC; 2013. Available from: http://ministryofhealth.gov.ky/sites/default/files/mental-health-laws-regs/Mental-Health-Law-2013.pdf.
10. Ministry of Health, Mental Health Commission (Cayman Islands). The mental health law: know the facts [brochure]. George Town: MOH; 2016. Available from: http://ministryofhealth.gov.ky/sites/default/files/brochure-mh-know-the-facts.pdf.
11. Pan American Health Organization. PAHO/WHO strategy for technical cooperation with the United Kingdom Overseas Territories (UKOTs) in the Caribbean 2016-2022. Washington, D.C.: PAHO; 2016. Available from: http://apps.who.int/iris/bitstream/10665/252648/1/ccs-UKOTs-2016-2022.en.pdf.
12. CTMH Doctors Hospital. About CTMH Doctors Hospital [Internet]. George Town: CTMH Doctors Hospital; 2017. Available from: http://doctorshospitalcayman.com/about-ctmh/.
13. Health City Cayman Islands. Health City Cayman Islands [Internet]. George Town: HCCI; 2016. Available from: https://www.healthcitycaymanislands.com/about/health-city/.
14. Mosquito Research and Control Unit (Cayman Islands). Mosquito Research and Control Unit [Internet]. George Town: MRCU; 2016. Available from: http://mrcu.ky/friendly-aedes-aegypti-project/ Accessed August 2016.
15. Ministry of Health, Environment, Youth, Sports and Culture (Cayman Islands). WHO STEPS chronic disease risk factor survey 2012. George Town: MHEYSC; 2014. Available from: http://www.ministryofhealth.gov.ky/sites/default/files/HEALTHY-NATION-RISK-FACTOR-SURVEY.pdf.
16. World Health Organization. WHO-AIMS report on mental health system in Cayman Islands. Geneva: WHO/Ministry of Health (Cayman Islands); 2014. Available from: http://www.ministryofhealth.gov.ky/sites/default/files/WHO-AIMS-report/WHO-AIMS-Report-Final.pdf Accessed August 2016.
17. University College of the Cayman Islands. Undergraduate catalogue 2016-2017. George Town: UCCI; 2016. Available from: http://www.ucci.edu.ky/_docs/catalogue/UCCI-Undergraduate-Catalogue-2016-17.pdf.
18. Office of the Auditor General (Cayman Islands). Cayman Islands health system. George Town: OAG; 2017. Available from: http://cnslibrary.com/wp-content/uploads/OAG-Report-Cayman-Islands-Health-System-January-2017.pdf.
19. Department of Environment (Cayman Islands). Climate change issues for the Cayman Islands: towards a climate change policy. George Town: DOE; 2011.
20. Department of Environmental Health (Cayman Islands). Solid waste statistics for January 2010 to December 2011. George Town: DEH; 2012. Available from: http://www.deh.gov.ky/portal/page/portal/dehhome/aboutus/STATISTICS/DEH%20solid%20waste%20statistics%20for%20Jan%202010%20to%20Dec%202011.pdf.
21. Amec Foster Wheeler Environment & Infrastructure UK Limited. National Solid Waste Management Strategy for the Cayman Islands: consultation draft. Warrington, UK: Amec Foster Wheeler; 2015. Available from: http://ministryofhealth.gov.ky/sites/default/files/National%20Solid%20Waste%20Management%20Strategy%20Report.pdf.
22. Royal Cayman Islands Police Service. Crime statistics for cumulative period 2015 vs. 2014 [Internet]. George Town: RCIPS; 2016. Available from: http://www.rcips.ky/portal/page/portal/polhome/foi/doclibrary/stats.
23. Department of Health Regulatory Services (Cayman Islands). Health Insurance Commission: FAQs [Internet]. George Town: DHRS; 2016. Available from: http://www.dhrs.gov.ky/portal/page/portal/hrshome/hic/hicfaq.
24. Cayman Islands National Insurance Company. About CINICO: history [Internet]. George Town: CINICO; 2016. Available from: https://www.cinico.ky/history#b.
25. Ministry of Health (Cayman Islands). Adolescent Health and Sexuality: a report on the adolescent health and sexuality survey, Cayman Islands 2013. George Town: MOH; 2013. Available from: http://ministryofhealth.gov.ky/sites/default/files/adolescent-health-and-sexuality-final-report.pdf Accessed August 2016.
26. Health Services Authority (Cayman Islands). Communicable diseases surveillance report 2014. George Town: HSA; 2015. Available from: https://www.hsa.ky/ContentFiles/Communicable%20Disease%20Surveillance%20Report%202014%20Amended%20(1).pdf Accessed August 2016.
27. Health Service Authority (Cayman Islands). Cayman Islands Health Services Authority Strategic Plan 2010-2018. George Town: HSA; [updated March 2016] 2015. Available from: https://www.hsa.ky/ContentFiles/Updated%20Strategic%20Plan.pdf.