Healthcare In Ghana Research Articles

Positioning the National Health Insurance for financial sustainability and Universal Health Coverage in Ghana: A qualitative study among key stakeholders.

IntroductionThe National Health Insurance Scheme (NHIS) was introduced in 2003 to reduce “out-of-pocket” payments for health care in Ghana. Over a decade of its implementation, issues about the financial sustainability of this pro-poor policy remains a crippling fact despite its critical role to go towards Universal Health Coverage. We therefore conducted this study to elicit stakeholders’ views on ways to improve the financial sustainability of the operations of NHIS.MethodsTwenty (20) stakeholders were identified from Ministry of Health, Ghana Health Services, health workers groups, private medical practitioners, civil society organizations and developmental partners. They were interviewed using an interview guide developed from a NHIS policy review and analysis. All interviews were recorded and transcribed verbatim. The data were analysed thematically with the aid of NVivo 12 software.ResultsStakeholders admitted that the NHIS is currently unable to meet its financial obligations. The stakeholders suggested first the adoption of capitation as a provider payment mechanism to minimize the risk of providers’ fraud and protection from political interference. Secondly, they indicated that rapid releases of specific statutory deductions and taxes for NHIS providers could reduce delays in claims’ reimbursement which is one of the main challenges faced by healthcare providers. Aligning the NHIS with the Community-based Health Planning and Services and including preventive and promotive health is necessary to position the Scheme for Universal Health Coverage.ConclusionThe Scheme will potentially achieve UHC if protected from political interference to improve the governance and transparency that affects the finances of the scheme and the expansion of services to include preventive and promotive services and cancers.

Health Service Activity Standards and Standard Workloads for Primary Healthcare in Ghana: A Cross-Sectional Survey of Health Professionals.

The attainment of health system goals is largely hinged on the health workforce availability and performance; hence, health workforce planning is central to the health policy agenda. This study sought to estimate health service activity standards and standard workloads at the primary health care level in Ghana and explore any differences across health facility types. A nationally representative cross-sectional survey was conducted among 503 health professionals across eight health professions who provided estimates of health service activity standards in Ghana’s Primary Health Care (PHC) settings. Outpatient consultation time was 16 min, translating into an annual standard workload of 6030 consultations per year for General Practitioners. Routine nursing care activities take an average of 40 min (95% CI: 38–42 min) for low acuity patients; and 135 min (95% CI: 127–144 min) for high dependency patients per inpatient day. Availability of tools/equipment correlated with reduced time on clinical procedure. Physician Assistants in health centres spend more time with patients than in district hospitals. Midwives spend 78 min more during vaginal delivery in health centres/polyclinics than in district/primary hospital settings. We identified 18.9% (12 out of 67) of health service activities performed across eight health professional groups to differ between health centres/polyclinics and district/primary hospitals settings. The workload in the health facilities was rated 78.2%, but as the workload increased, and without a commensurate increase in staffing, health professionals reduced the time spent on individual patient care, which could have consequences for the quality of care and patient safety. Availability of tools and equipment at PHC was rated 56.6%, which suggests the need to retool these health facilities. The estimated standard workloads lay a foundation for evidence-based planning for the optimal number of health professionals needed in Ghana’s PHC system and the consequent adjustments necessary in both health professions education and the budgetary allocation for their employment. Finally, given similarity in results with Workload Indicators of Staffing Need (WISN) methodology used in Ghana, this study demonstrates that cross-sectional surveys can estimate health service activity standards that is suitable for health workforce planning just as the consensus-based estimates advocated in WISN.

Socio-economic impact of COVID-19 on Ghana's economy: challenges and prospects

PurposeThe world's economies are on their knees following the negative impact of the coronavirus pandemic over the past 8 months. Growing number of researches has been conducted on the impact of COVID-19 pandemic on developed countries with little attention on developing countries, who are still grappling with the negative impact of the coronavirus. The rationale for this study is to assess the socio-economic impact of COVID-19 on Ghana's economy and government response to the pandemic as well as policy options to revive the ailing economy.Design/methodology/approachThis study explored the socio-economic impact of the coronavirus on Ghana's economy using a discourse analysis with data from various secondary sources to analyze the impact of the pandemic from the Ghanaian perspective.FindingsThe findings from the discourse analysis revealed that the coronavirus pandemic has negatively impacted on the socio-economic situation of the citizens of Ghana. Whiles an estimated 42,000 people lost their jobs in the first two months of the pandemic in Ghana, tourist attraction sector of the country alone lost $171 million dollars in the past three months due to the partial lockdown and closure of tourism and hospitality centers in the country. The study revealed that Ghana's healthcare system has been overwhelmed by the number of increasing cases in the country to extent of making use of temporary structures as isolation and treatment centers of the pandemic. The study revealed that Ghana may convert these challenges posed by the COVID-19 pandemic into prospects and opportunities by investing massively in the health sector and creating support for the SMEs which creates massive employment for many Ghanaians.Research limitations/implicationsThis study focuses on the impact of the COVID-19 on Ghana's economy and how the pandemic has negatively affected the country. The study is an exploratory study that makes use of secondary data. However, conducting a study with primary data sources from specific communities or regions in the country may not produce the same results. The results from the primary level or community level may be different from the general results obtained from the study. In future it is expected that the study focuses specifically on the extent of the coronavirus pandemic on Ghana's fiscal deficit which seems to have ballooned in recent times.Originality/valueThe study is the first of its kind to extensively explore the socio-economic impact of the COVID-19 pandemic on the Ghanaian economy. The novelty of this paper is that it recognizes governments response to the pandemic and proposes three practical measures adopted to put the country's economy back on its feet through survive, revive and ensuring growth in all sectors of the economy.

Older people's challenges and expectations of healthcare in Ghana: A qualitative study.

The increase in the number of elderly persons in developing countries has not had a corresponding increase in social and health care support systems for the elderly. There is a substantial difference in the quality of healthcare received by older people in developing and developed countries. Elderly persons in developing countries including Ghana are increasingly becoming marginalised and isolated. There is, however, limited evidence of healthcare challenges and expectations by elderly persons in Ghana. This study explored healthcare challenges and expectations of elderly persons to inform policy that could lead to improved quality of life for elderly persons in Ghana. Qualitative exploratory descriptive study design was used in conducting this study. Semi-structured interviews were used in collecting data from 30 participants from three regions in Ghana (10 from each region). Data analysis was carried out through content analysis. Four themes were extracted from data. These themes were: 1. Inadequate information from health workers regarding care of the older person. 2. Queuing frustrations. 3. Financial burden. 4. Focused elderly care demand. The elderly in Ghana experience challenges of healthcare which include inadequate information, queuing frustrations and financial burdens. Elderly persons also have expectations of healthcare which include having dedicated professionals and units that will attend to them during their hospital visits. Academic and clinical gerontology experts could collaborate and help improve gerontology knowledge of health workers through workshops and conferences. Improving knowledge of health workers in gerontology may be a positive step towards meeting healthcare expectations of older Ghanaians.

Covid-19, Health Care in Ghana and the Fundamental Laws of Medical Science

The purpose of this article is to provide an overview of available research concerning covid-19 in Ghana. It presents challenges, measures from the health care delivery sector in the public health facilities. The article draws some strength from the fundamental laws of medicine as they aid to prepare the scientists in their combat against the novel Covid-19, its variants such as Delta and Omicron. Though the government has suffered economically from lockdowns and social interventions, its resilience efforts have been acclaimed to be successful and have to be emulated by other countries. The health care workers in Ghana's dissatisfaction with their jobs in these periods have not sidelined government efforts to lead and care for its citizens amid a pandemic.

Children’s Nurses’ Knowledge and Attitudes on Paediatric Pain: A Descriptive Cross-Sectional Survey in a Developing Country

Background: Children’s nurses’ knowledge of pain affects their pain management practices. Even though poor knowledge and attitudes have been reported in several studies, most were carried out in developed settings. However, little has been reported on the management of paediatric pain by nurses in resource-limited settings such as in sub-Saharan Africa.Purpose: This study sought to assess the knowledge and perceptions of children’s nurses regarding paediatric pain in a Ghanaian context.Methodology: A descriptive cross-sectional survey was carried out among 65 nurses at eight hospitals at various levels of healthcare in Ghana. Over three months, participants’ demographic data and responses on the Pediatric Nurses Knowledge and Attitude Survey Regarding Pain (PNKAS) instrument were collected. Data were analyzed and presented using descriptive and inferential statistics.Results: Participants’ average (SD) knowledge and attitudes regarding paeditric pain was 36.7% (6.9%) and ranged from 21.4% to 57.1%. Pediatric pain knowledge and attitudes (PPKA) of the nurses differed based on working years in the children’s unit and the hospital type they worked in (p<0.05). Nevertheless, the type of hospital facility was the only independent predictor of their PPKA (R2=0.181, p<0.001).Conclusion: Children nurses in this setting generally had insufficient knowledge and attitudes on paediatric pain. They should be motivated to undertake self-directed learning and regular continuing professional education to update their knowledge, attitude and skills on evidence-based pediatric pain assessment and management.

An assessment of the health sustainability of sanitation in Ghana: A quantitative analysis

The present study aims to assess the improvements of sanitation system of Kumasi metropolitan area. Sanitation conditions in Africa remain awful with approximately 20% of the population reported to still engage in open defecation in Sub‐Saharan Africa, despite major improvements in other climes of the world. In Ghana, the impacts of poor sanitation systems range from negatively impacting natural resources water quality, to causing health threats to the populations involved. Using health as selected sustainable sanitation, this research assesses reported cases of diseases and deaths associated with unsatisfactory sanitation from 2008 to 2015. Both primary and secondary data were employed. The primary data was collected through interview with key informants by purposive sampling. Quantitative data were analyzed via primary descriptive statistical methods. Results indicate slight improvements in the sanitation system. Our findings suggest that the number of diseases is high due to poor sanitation. However, statistics of deaths are minimal, and these were ascribed to improvements in health care in Ghana. The study has offered recommendations in order to improve sanitation system within the metropolis toward more sustainability. The research is significant because theory developers, researchers, policy makers, and practitioners can make use of its findings to tackle the problems of sustainable sanitation since theories and practices of sustainable sanitation are constantly evolving.

Geographical access to point-of-care testing for hypertensive disorders of pregnancy as an integral part of maternal healthcare in Ghana

BackgroundHypertensive disorders of pregnancy (HDP) are associated with high maternal mortality in Ghana and globally. Evidence shows that there is poor availability of pregnancy-related point-of-care (POC) tests in Ghana’s primary healthcare (PHC) clinics (health centre or community-based health planning services facilities). Therefore, we employed geographic information systems to estimate the geographical distribution of and physical accessibility to HDP POC testing services in the Upper East Region (UER), Ghana.MethodsWe collected data on 100 out of 365 PHC clinics, public hospitals providing HDP testing, PHC clinic type, ownership, and availability of urine dipsticks and blood pressure (BP) devices. We also obtained the geo-located data of the PHC clinics and hospitals using the global positioning system. We employed ArcGIS 10.4 to measure the distance and travel time from the location of each PHC clinic without HDP POC testing services as well as from all locations of each district to the nearest hospital/clinic where the service is available. The travel time was estimated using an assumed motorised tricycle speed of 20 km/hour. We further calculated the spatial distribution of the hospitals/clinics providing HDP POC testing services using the spatial autocorrelation tool in ArcMap, and Stata version 14 for descriptive statistical analysis.ResultsOf the 100 participating PHC clinics, POC testing for HDP was available in 19% (14% health centres and 5% community-based health planning services compounds) in addition to the 10 hospitals use as referral points for the service. The findings indicated that the spatial pattern of the distribution of the health facilities providing HDP POC testing was random (z-score = -0.61; p = 0.54). About 17% of the PHC clinics without HDP POC testing service were located > 10 km to the nearest facility offering the service. The mean distance and travel time from PHC clinics without HDP POC testing to a health facility providing the service were 11.4 ± 9.9 km and 31.1 ± 29.2 min respectively. The results suggest that if every 19% of the 365 PHC clinics are offering HDP POC testing in addition to these 10 hospitals identified, then the estimated coverage (health facility-to-women in fertility age ratio) in the UER is 1: 3,869.ConclusionsThere is poor physical accessibility to HDP POC testing services from PHC clinics without HDP POC testing in the UER. Mothers who obtain maternal healthcare in about 17% of the PHC clinics travel long distances (> 10 km) to access the service when needed. Hence, there is a need to improve the availability of HDP POC diagnostic tests in Ghana’s rural clinics.

Primary health care in Ghana: the structure and functions in relation to preventing neglected tropical diseases

Primary health care in Ghana: the structure and functions in relation to preventing neglected tropical diseases

Accessing Healthcare in Ghana: Challenges Encountered and Strategies Adopted by Persons with Disabilities in Accra

Purpose: Access to quality and timely healthcare is essential to the health and wellbeing of all individuals. Unfortunately, the more vulnerable populations, such as persons with disabilities, encounter a number of barriers in accessing healthcare services. This study focusses on barriers that persons with disabilities face in accessing healthcare in the Accra metropolis, and the strategies they adopt when they are ill. Method: A phenomenological approach was employed to achieve a deeper and holistic understanding of the challenges encountered when accessing healthcare. Purposive sampling technique was used to recruit 21 persons with disabilities, between 18 and 64 years of age, from the organisations of persons with disabilities in Accra. Results: The study revealed that physical, financial, communication, transportation, and attitudinal barriers, as well as healthcare professionals’ lack of knowledge about disability issues, limited access of persons with disabilities to healthcare. The majority of persons with disabilities preferred to stay at home and self-medicate or depend on herbal medicine, rather than seek help from healthcare professionals. Conclusion: Healthcare for all is a right that every human being is entitled to, irrespective of disability. The removal of barriers restricting access to healthcare for persons with disabilities is a necessity to achieve Goal 3 of the Sustainable Development Goals (SDG) Agenda 2030.

Do Health Insurance Scheme affect the Livelihood of People in the Rural Area of Ghana: Empirical Evidence from Adaklu Anyigbe

The main objective of establishing the National Health Insurance Scheme (NHIS) is to protect the poor and put health in the hands of the people. It also aims to provide health services for all by abolishing the "cash and carry" system in which patients are asked to pay before they are treated. This study was conducted to assess a new method of financing Health Care in Ghana, evaluation of Mutual Health Insurance Scheme in Adaklu Anyigbe. A questionnaire was designed using structured questions to collect primary data from health facilities and clients of the NHIS. Personal interviews were held to solicit views and comments from some respondents. The results show that the availability of adequate funds for health care services is very important for the survival of the health insurance scheme. Adequate funding for health care services will assist in meeting health care services and delivery requirements for health service facilities and clients in Ghana. Meeting Ghana's health requirements will require the adoption of effective policies and guiding principles that integrate the input and concerns of all stakeholders from the health care business.

Assessing Total Quality Management (TQM) Effect on Hospital Performance in Ghana Using a Non-Probabilistic Approach: The Case of Greater Accra Regional Hospital (GARH)

Background: TQM has gained extensive prominence over the last few decades and continue to play a significant role in modern healthcare delivery. Objectives: The objective of this empirical inquiry is to explore the nexus between TQM critical success factors implementation and hospital performance by soliciting employee and patient’s views within the Ghanaian context, focusing on Greater Accra Regional Hospital, a prime provider of secondary public healthcare in Ghana. Methods: A cross-sectional approach (research design) was espoused for the study which made use of quantitative research techniques for its analysis. The study was based on self-answering structured (close-end) questionnaires completed by 250 respondents selected via convenient sampling. SPSS 25.0 was utilised for data analysis. Statistical analyses include descriptive statistics, principal component analyses, exploratory factor analyses with varimax rotation, reliability analyses, and multivariate regression analyses. Results: The study found significant positive relationships between all nine TQM constructs and hospital performance. Findings further revealed that the top management leadership construct contributed most to hospital performance, while training contributed least. Conclusion: The study made recommendations that have practical implications for hospital administrators/managers. In this circumstance, findings/recommendations established, should be considered crucial for hospital administrators/managers and policy makers when dealing with decisions affecting TQM assessment by exploring the potential practicability of the nine TQM critical success factors utilised in this study as a pertinent contrivance for initiating continuous service improvement in GARH in particular and Ghana’s public healthcare sector in general.

Partnership and collaboration in healthcare delivery in Ghana

The quest of most state or governments to adequately cater for the healthcare needs of its people continue to be a difficult task since many states have experienced, and continue to experience, a reduction in allocation of resources to the health sector. The involvement of the private sector in health care delivery is an option being explored by a number of states to augment resources in the health sector with some partnerships between the public and the private healthcare facilities in the fight against AIDS, Tuberculosis and Malaria. However, not many empirical studies have been conducted to identify and better understand these partnerships between the state agencies and the private sector in Ghana. This study, therefore, sought to answer questions on the range of partnership and collaborative activities existing between public and private healthcare institutions in Ghana, the need for these collaborations and the factors that hinder these collaborations in Ghana. The study adopted the stakeholder theory as various stakeholders come together to ensure the delivery of healthcare in Ghana. The study revealed that there was no direct partnership between these two groups. They, however, collaborated in some instances under the umbrella of their governing organization. The perceived need for collaboration that was identified under the study was for the protection of human lives. The study concluded that this collaboration is necessary to ensure an efficient healthcare delivery.

Stakeholders' perspectives about the impact of training and sensitization of traditional and spiritual healers on mental health and illness: A qualitative evaluation in Ghana.

Prayer camps and traditional healers have emerged recently as alternative sources of mental health care in Ghana. To increase their knowledge and collaboration between formal and informal mental health care providers, training and sensitization was organized for them. This study aimed at assessing beneficiaries' views about the impact of this intervention. We adopted narrative approach to qualitative enquiry using purposive sampling strategy to recruit formal and informal mental health care providers in Ghana for an in-depth interview. We analyzed the data thematically using QSR NVivo 12. Participants enhanced their knowledge about mental health and illness. They reported increased collaboration between formal and informal health care providers. Community psychiatric nurses (CPNs) give injections to patients instead of chaining and using shackles as was initially practiced. There are also regular visits by CPNs to traditional and spiritual healers to discuss the care of the mentally ill patients in their facilities. There has been an increased collaboration among healers of mental illness resulting in quick recovery of patients who seek care at traditional and spiritual healers. There is also abolition of chaining and using of shackles by these healers, with increasing respect for the human rights of patients.

Clinic-Based Pediatric Disclosure Intervention Trial Improves Pediatric HIV Status Disclosure in Ghana.

Disclosing HIV status to HIV-positive children is a major challenge facing families and health care providers. Despite recommendations for disclosure, rates remain low. We tested whether a pediatric HIV disclosure intervention delivered as an integral component of routine HIV health care in Ghana would improve disclosure to children. Dyads of HIV-infected children aged 7-18 years and their caregivers were enrolled from 2 HIV clinics in Accra and Kumasi, Ghana. The sites were randomly assigned to one of the 2 intervention arms to avoid treatment contamination between intervention and control participants. Trained interventionist used theory-guided therapeutic communication and personalized interaction to promote disclosure. Disclosure outcomes were measured at 12-week intervals. All analyses were completed using a modified intention-to-treat approach. We enrolled 446 child-caregiver dyads (N = 240 intervention group; N = 206 control group); 52% of the children were boys, mean age 9.78 (±2.27) years. For disclosure at 1 year, a better overall treatment effect was observed (P < 0.001). Children in the treatment group had greater disclosure at each time point (P < 0.001) and a higher proportion of them had been disclosed to by 1 year (51.4% vs. 16.2%; P < 0.001; un-adjusted hazard ratio = 3.98: 95% confidence interval: 2.63 to 6.03) and 3 years (71.3% vs. 34.0%; unadjusted hazard ratio = 4.21: 95% confidence interval: 3.09 to 5.72). In the multivariate Cox model, factors associated with disclosure were treatment group (P < 0.001), children <11 years of age (P < 0.001), HIV-infected caregivers (P = 0.015), and caregiver's with greater education (P = 0.022). This practical clinic-based disclosure intervention shows excellent promise as a means of improving HIV pediatric disclosure outcomes.

Strengthening Community-based Healthcare in Ghana in the Context of the TICAD Process: Promoting Resilient Healthcare Systems

Strengthening Community-based Healthcare in Ghana in the Context of the TICAD Process: Promoting Resilient Healthcare Systems

訳：牧野 久美子 抄訳：TICADプロセスの文脈におけるガーナのコミュニティベース保健強化――強靭な保健システム促進――

訳：牧野 久美子 抄訳：TICADプロセスの文脈におけるガーナのコミュニティベース保健強化――強靭な保健システム促進――

Exploring Conscientious Objection to Abortion Among Health Providers in Ghana

Few studies have explored clinicians' roles in the abortion experience in Ghana. Examining how clinicians understand conscientious objection to abortion-the right to refuse to provide legal abortion on the basis of moral or personal beliefs-may provide insight that could help manage the practice. Eight in-depth interviews and four focus group discussions were conducted with 14 doctors and 20 midwives in health facilities in Ghana's Eastern and Volta Regions in May 2018. The semi-structured interview guides covered such topics as clinicians' understanding of conscientious objection, how it is practiced and the consequences of conscientious objection for providers and clients. The data were analyzed using thematic analysis. Most clinicians did not understand the term "conscientious objection," and midwives had more knowledge on the subject than doctors. The main reasons for conscientious objection were antiabortion religious and cultural beliefs. Clinicians who objected referred clients to willing providers, counseled them to continue the pregnancies or inadvertently encouraged unsafe abortions. The negative consequences of conscientious objection to abortion for clients were complications and death from unsafe abortions; the consequences for providers included high patient volume and stigma for nonobjectors, leading some to claim objection to avoid these. The findings highlight the need for further research on the consequences of conscientious objection, including stigma leading to refusals. Such research may ultimately help to restrict clinicians' misuse of the right to object and improve women's reproductive health care in Ghana.

Estimating the Spatial Accessibility to Blood Group and Rhesus Type Point-of-Care Testing for Maternal Healthcare in Ghana.

Background: In Ghana, a blood group and rhesus type test is one of the essential recommended screening tests for women during antenatal care since blood transfusion is a key intervention for haemorrhage. We estimated the spatial accessibility to health facilities for blood group and type point-of-care (POC) testing in the Upper East Region (UER), Ghana. Methods: We assembled the attributes and spatial data of hospitals, clinics, and medical laboratories providing blood group and rhesus type POC testing in the UER. We also obtained the spatial data of all the 131 towns, and 94 health centres and community-based health planning and services (CHPS) compounds providing maternal healthcare in the region. We further obtained the topographical data of the region, and travel time estimated using an assumed tricycle speed of 20 km/h. We employed ArcGIS 10.5 to estimate the distance and travel time and locations with poor spatial access identified for priority improvement. Findings: In all, blood group and rhesus type POC testing was available in 18 health facilities comprising eight public hospitals and six health centres, one private hospital, and three medical laboratories used as referral points by neighbouring health centres and CHPS compounds without the service. Of the 94 health centres and CHPS compounds, 51.1% (48/94) and 66.4% (87/131) of the towns were within a 10 km range to a facility providing blood group and rhesus type testing service. The estimated mean distance to a health facility for blood group and rhesus POC testing was 8.9 ± 4.1 km, whilst the mean travel time was 17.8 ± 8.3 min. Builsa South district recorded the longest mean distance (25.6 ± 7.4 km), whilst Bongo district recorded the shortest (3.1 ± 1.9 km). The spatial autocorrelation results showed the health facilities providing blood group and rhesus type POC testing were randomly distributed in the region (Moran Index = 0.29; z-score = 1.37; p = 0.17). Conclusion: This study enabled the identification of district variations in spatial accessibility to blood group and rhesus type POC testing in the region for policy decisions. We urge the health authorities in Ghana to evaluate and implement recommended POC tests such as slide agglutination tests for blood group and rhesus type testing in resource-limited settings.

“Do Health Insurance Scheme’’ Affect the Livelihood of People in the Rural Area of Ghana: Emperical Evidence from Adaklu Anyigbe

The main objective of establishing the National Health Insurance Scheme (NHIS) is to protect the poor and put health in the hands of the people. It also aim to provide health services for all by abolishing the "cash and carry" system in which patients are asked to pay before they are treated. This study was conducted to assess a new method of financing Health Care in Ghana, evaluation of Mutual Health Insurance Scheme in Adaklu Anyigbe. A questionnaire was designed using structured questions to collect primary data from health facilities and clients of the NHIS. Personal interviews were held to solicit views and comments from some respondents. The results show that the availability of adequate funds for health care services is very important for the survival of the health insurance scheme. Adequate funding for health care services will assist in meeting health care services and delivery requirements for health service facilities and clients in Ghana. Meeting Ghana's health requirements will require the adoption of effective policies and guiding principles that integrate the input and concerns of all stakeholders from the health care business. Keywords; Health insurance scheme; Health care delivery; rural people; Adaklu Anyigbe DOI : 10.7176/EJBM/11-26-11 Publication date :September 30 th 2019