Connecting Health and Social Services for Patients with Complex Care Needs: A Pan-Canadian Comparative Policy Research Program.

Comprehensive primary healthcare for patients with complex care needs requires connections to other health services, social services and community supports. This descriptive comparative policy research program used publicly available documents and informant interviews to examine progress toward integrated comprehensive care through the lens of services needed by children and youth (0-25 years) and community-dwelling older adults (≥ 65 years) with high functional health needs. This article describes five projects. The following three findings emerged across all the projects: Canada indeed has multiple health systems; numerous integrated service delivery solutions are being trialled and most focus on medical services; and it is an ongoing challenge for ministries of health to engage physicians and physician associations in integration.

Inconsistent Governance Structures for Health and Social Services Limit Service Integration for Patients with Complex Care Needs.

This paper describes how health and social services are governed and organized across Canada for two patient groups. Governance configurations and governance proximity between primary care and priority health and social services varied markedly between provinces. While the need for integrated service delivery has been made a clear priority during the COVID-19 pandemic, the potential of Canada's healthcare systems has not yet translated into coordinated and integrated care for health services, much less for health and social services. It is time to act on the policy recommendations from commissioned reports over the past two decades that focus on comprehensive, community-based care.

Toward Comprehensive Care Integration in Canada: Delphi Process Findings from Researchers, Clinicians, Patients and Decision Makers.

Introduction: From a larger study examining policy and program information on how Canadian provinces integrate care services, this study aimed to create "priority lists" of 10-15 services that are "absolutely needed" for care integration. Methodology: A diverse group of over 50 Canadian stakeholders participated in virtual consensus-building using the nominal group technique and a modified e-Delphi method to identify services that focused on two different groups: children and youth with high functional health needs and older adults in functional decline. Results: Three lists - containing services, processes and infrastructure elements - emerged: one per tracer condition group and a consolidated list. The latter identified the following five services as top priority for primary care integration: mental health and addictions services; home care; transition between urgent-emergency-acute care; medication reconciliation in community pharmacies; and respite care. No single social service was a clear priority, but those that mitigate material deprivation emerged within the top 10. Discussion: This humble pan-Canadian study shows that priority services in health and social services are neither well integrated nor connected to primary care. It also suggests that effective policy strategizing for primary care integration for those with complex care needs may require thinking beyond the logic of services - given their siloed organization.

Have Primary Care Renewal Initiatives in Canada Increased Comprehensive Care for Patients with Complex Care Needs? Yes and No.

The First Ministers Health Accords of 2001 through 2003 (Health Canada 2006) launched the renewal of primary care toward more comprehensive care delivery models. We scanned government websites in the 10 Canadian provinces to assess how comprehensive and integrated renewal models were for health and social services in 2018. More comprehensive primary care delivery models were the norm in five out of 10 provinces. The policy approaches were: (1) expanding traditional family practice; (2) creating primary care networks; and (3) increasing the number of community health centres, which provide the broadest range of health and social care. Integration initiatives were limited to medical services. Additional financial and policy investments will be required to meet the comprehensive needs of patients with complex health and social needs at a system level.

Innovative Programs with Multi-Service Integration for Children and Youth with High Functional Health Needs.

The integration of care services and providers across the health-social-community continuum has helped improve the lives of many children and youth living with complex health conditions. Using environmental scan data, 16 promising multi-service programs were selected and analyzed qualitatively through a deliberative conversation approach. Descriptive data of analyzed programs are presented, as well as the thematic analysis results. An important program strength is its clear founding principles and engagement of patients and families. However, the scale-up of these initiatives remains a challenge unless such programs can be better financed and supported.

Integrating Health and Social Care for Community-Dwelling Older Adults: A Description of 16 Canadian Programs.

This paper describes 16 Canadian programs designed to provide integrated primary care for older adults. Publicly available data were used to identify the "what" and the "how" of integration for each program. Most programs integrated with other healthcare or medical services (vs. social services). Mechanisms of integration varied; the most common mechanism was interprofessional teams. Only 25% of the programs formally engaged with autonomous physician-led primary care practices (where most Canadians receive their primary care). Findings suggest that integrated care is a priority across Canada but also highlight how far we have to go to achieve both vertical integration within the healthcare sector (primary, secondary and tertiary services) and horizontal integration across sectors (health and social).

Lack of Publicly Available Documentation Limits Spread of Integrated Care Innovations in Canada.

As healthcare in Canada is provincially operated, the program innovations in one jurisdiction may not be readily known in other jurisdictions. We examine the availability of implementation-specific data for 30 innovative Canadian programs designed to integrate health and social services for patients with complex needs. Using publicly available data and key informant interviews, we were able to populate only ∼50% of our data collection tool (on average). Formal program evaluations were available for only ∼30% of programs. Multiple barriers exist to the compilation and verification of healthcare programs' implementation data across Canada, limiting cross-jurisdictional learning and making a comparison of programs challenging.

Patient Partners Respond to High-Level Findings on the Connectedness of Health and Social Services across Canada.

This short article captures input from patient partners on the dimensions of the research program that most resonated with them. They are passionate about wanting to see a better connection between health and social services, and they are also willing to be involved as advisors for policy directions in the same way as their involvement has become the norm in any patient-oriented research.

A longitudinal multi-site evaluation of community-based partnerships: implications for researchers, funders, and communities.

BACKGROUND: Innovative Models Promoting Access to Care Transformation (IMPACT) was a five-year (2013-2018), Canadian-Australian research program that aimed to use a community-based partnership approach to transform primary health care (PHC) organizational structures to improve access to appropriate care for vulnerable populations. Local Innovation Partnerships (LIPs) were developed to support the IMPACT research program, and to be ongoing structures that would continue to drive local improvements to PHC. METHODS: A longitudinal development-focused evaluation explored the overall approach to governance, relationships and processes of the LIPs in the IMPACT program. Semi-structured interviews were conducted with purposively selected participants including researchers with implementation roles and non-researchers who were members of LIPs at four time points: early in the development of the LIPs in 2014; during intervention development in 2015/2016; at the intervention implementation phase in 2017; and nearing completion of the research program in 2018.  A hybrid deductive-inductive thematic analysis approach was used. A Guide developed to support the program was used as the framework for designing questions and analysing data using a qualitative descriptive method initially. A visual representation was developed and refined after each round of data collection to illustrate emerging themes around governance, processes and relationship building that were demonstrated by IMPACT LIPs. After all rounds of data collection, an overarching cross-case analysis of narrative summaries of each site was conducted. RESULTS: Common components of the LIPs identified across all rounds of data collection related to governance structures, stakeholder relationships, collaborative processes, and contextual barriers.  LIPs were seen primarily as a structure to support implementation of a research project rather than an ongoing multisectoral community-based partnership.  LIPs had relationships with many and varied stakeholders although not necessarily in ways that reflected the intended purpose. Collaboration was valued, but multiple barriers impeded the ability of LIPs to enact real collaboration in daily operations over time. We learned that experience, history, and time matter, especially with respect to community-oriented collaborative skills, structures, and relationships. CONCLUSIONS: This longitudinal multiple case study offers lessons and implications for researchers, funders, and potential stakeholders in community-based participatory research.

Co-designing person-centred quality indicator implementation for primary care in Alberta: a consensus study.

BACKGROUND: We aimed to contribute to developing practical guidance for implementing person-centred quality indicators (PC-QIs) for primary care in Alberta, Canada. As a first step in this process, we conducted stakeholder-guided prioritization of PC-QIs and implementation strategies. Stakeholder engagement is necessary to ensure PC-QI implementation is adapted to the context and local needs. METHODS: We used an adapted nominal group technique (NGT) consensus process. Panelists were presented with 26 PC-QIs, and implementation strategies. Both PC-QIs and strategies were identified from our extensive previous engagement of patients, caregivers, healthcare providers, and quality improvement leaders. The NGT objectives were to: 1. Prioritize PC-QIs and implementation strategies; and 2. Facilitate the participation of diverse primary care stakeholders in Alberta, including patients, healthcare providers, and quality improvement staff. Panelists participated in three rounds of activities. In the first, panelists individually ranked and commented on the PC-QIs and strategies. The summarized results were discussed in the second-round face-to-face group meeting. For the last round, panelists provided their final individual rankings, informed by the group discussion. Finally, we conducted an evaluation of the consensus process from the panelists' perspectives. RESULTS: Eleven primary care providers, patient partners, and quality improvement staff from across Alberta participated. The panelists prioritized the following PC-QIs: 'Patient and caregiver involvement in decisions about their care and treatment'; 'Trusting relationship with healthcare provider'; 'Health information technology to support person-centred care'; 'Co-designing care in partnership with communities'; and 'Overall experience'. Implementation strategies prioritized included: 'Develop partnerships'; 'Obtain quality improvement resources'; 'Needs assessment (stakeholders are engaged about their needs/priorities for person-centred measurement)'; 'Align measurement efforts'; and 'Engage champions'. Our evaluation suggests that panelists felt that the process was valuable for planning the implementation and obtaining feedback, that their input was valued, and that most would continue to collaborate with other stakeholders to implement the PC-QIs. CONCLUSIONS: Our study demonstrates the value of co-design and participatory approaches for engaging stakeholders in adapting PC-QI implementation for the primary care context in Alberta, Canada. Collaboration with stakeholders can promote buy-in for ongoing engagement and ensure implementation will lead to meaningful improvements that matter to patients and providers.

Person-centred care (PCC) is a model of care where patient needs and preferences are included in decisions about care and treatment. To improve PCC in primary care in Alberta, Canada, we plan to use person-centred quality indicators (PC-QIs). Using PC-QIs involves surveying patients about their care experiences and using this information to make improvements. For example, if 20% of patients do not feel they are getting enough information, the clinic may create a checklist for the providers so information is not missed. We engaged a panel of 11 people, including patients, family doctors, and staff who support quality improvement in clinics across the province to decide together which PC-QIs primary care clinics in Alberta should use. We also asked the panel to decide the most important strategies that would make using the PC-QIs more successful. The panel chose PC-QIs related to: patient and caregiver involvement in decisions about care and treatment, a trusting relationship with the healthcare provider, having health information technology to support PCC, partnering with communities in healthcare, and the patient's overall experience. The most important strategies were: developing partnerships among people working in primary care in Alberta, discussing their needs and common efforts for improving PCC, engaging "champions," and securing funding that would be needed. Finally, we asked the panelists to share their experiences with participating in this process. Panelists found the process useful and that their input was valued. Most panelists would also like to continue to work together to put the PC-QIs into practice.

Informing the implementation and use of person-centred quality indicators: a mixed methods study on the readiness, barriers and facilitators to implementation in Canada.

OBJECTIVES: To ensure optimal implementation of person-centred quality indicators (PC-QIs), we assessed the readiness of Canadian healthcare organisations and explored their perceived barriers and facilitators to implementing and using PC-QIs. DESIGN: Mixed methods. SETTING AND PARTICIPANTS: Representatives of Canadian healthcare delivery and coordinating organisations that guide the development and/or implementation of person-centred care (PCC) measurement. Representatives from primary care clinics and organisations from the province of Alberta, Canada also participated. METHODS: We conducted a survey with representatives of Canadian healthcare organisations. The survey comprised two sections that: (1) assessed readiness for using PC-QIs, and (2) were based on the Organizational Readiness for Change Assessment tool. We summarised the survey results using descriptive statistics. We then conducted follow-up interviews with organisations representing system and clinical-level perspectives to further explore barriers and facilitators to implementing PC-QIs. The interviews were informed by and analysed using the Consolidated Framework for Implementation Research. RESULTS: Thirty-three Canadian regional healthcare organisations across all 13 provinces/territories participated in the survey. Only 5 of 26 PC-QIs were considered highly feasible to implement for 75% of organisations and included: coordination of care, communication, structures to report performance, engaging patients and caregivers and overall experience. A representative sample of 10 system-level organisations and 11 primary care organisations/clinics participated in the interviews. Key barriers identified were: resources and staff capacity for quality improvement, a shift in focus to COVID-19 and health provider motivation. Facilitators included: prioritisation of PCC measurement, leadership and champion engagement, alignment with ongoing provincial strategic direction and measurement efforts, and the use of technology for data collection, management and reporting. CONCLUSIONS: Despite high interest and policy alignment to use PC-QI 'readiness' to implement them effectively remains a challenge. Organisations need to be supported to collect, use and report PCC data to make the needed improvements that matter to patients.

The effectiveness of person-centred quality improvement strategies on the management and control of hypertension in primary care: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of person-centred quality improvement strategies on the management and control of adults with hypertension in primary care. METHODS: A systematic review and meta-analysis was conducted using the Medline, Cochrane Central Register for Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, and APA PsycINFO databases (January 1980 to March 2020). Randomized controlled trials that evaluated person-centred quality improvement strategies for the management and control of essential hypertension among adults ( ≥ 18 years) in primary care were included. Random effects models were used to estimate weighted mean differences (WMD) for the change in systolic and diastolic blood pressures (SBP, DBP) from baseline; risk ratios (RR) were calculated for the proportion of participants achieving target blood pressures, for each quality improvement strategy assessed. A qualitative review of the implementation details of the interventions was conducted to identify common components of interventions that were effective in improving blood pressure outcomes. RESULTS: Eight studies were included (total of 5654 patients). Findings favour use of person-centred quality improvement interventions over usual care (RR = 1.23 [95% CI: 1.01; 1.48]) for improving blood pressure outcomes. Self-management (RR = 1.43 [95% CI: 1.23; 1.65]) had the greatest effects on blood pressure targets. Clinician education resulted in the greatest SBP reduction (WMD:6.09 mmHg [95% CI: 2.32; 9.85]), while patient education and patient reminder systems (both WMD:4.86 mmHg [95% CI: 0.88; 8.83]) saw the most improvements in DBP. While interventions varied in their strategy implementation, common features of effective interventions included tailored communication with patients, use of health information technology, and multidisciplinary collaboration. CONCLUSION: Person-centred quality improvement strategies were effective in improving blood pressure outcomes. Further research is needed regarding the context of implementing interventions to provide greater insight into the components of a person-centred quality improvement intervention most effective in improving hypertension outcomes.

Human Babesiosis Caused by Babesia duncani Has Widespread Distribution across Canada.

Human babesiosis caused by Babesia duncani is an emerging infectious disease in Canada. This malaria-like illness is brought about by a protozoan parasite infecting red blood cells. Currently, controversy surrounds which tick species are vectors of B. duncani. Since the availability of a serological or molecular test in Canada for B. duncani has been limited, we conducted a seven-year surveillance study (2011⁻2017) to ascertain the occurrence and geographic distribution of B. duncani infection country-wide. Surveillance case data for human B. duncani infections were collected by contacting physicians and naturopathic physicians in the United States and Canada who specialize in tick-borne diseases. During the seven-year period, 1119 cases were identified. The presence of B. duncani infections was widespread across Canada, with the highest occurrence in the Pacific coast region. Patients with human babesiosis may be asymptomatic, but as this parasitemia progresses, symptoms range from mild to fatal. Donors of blood, plasma, living tissues, and organs may unknowingly be infected with this piroplasm and are contributing to the spread of this zoonosis. Our data show that greater awareness of human babesiosis is needed in Canada, and the imminent threat to the security of the Canadian blood supply warrants further investigation. Based on our epidemiological findings, human babesiosis should be a nationally notifiable disease in Canada. Whenever a patient has a tick bite, health practitioners must watch for B. duncani infections, and include human babesiosis in their differential diagnosis.

Introduction of new technologies and decision making processes: a framework to adapt a Local Health Technology Decision Support Program for other local settings.

PURPOSE: Introducing new health technologies, including medical devices, into a local setting in a safe, effective, and transparent manner is a complex process, involving many disciplines and players within an organization. Decision making should be systematic, consistent, and transparent. It should involve translating and integrating scientific evidence, such as health technology assessment (HTA) reports, with context-sensitive evidence to develop recommendations on whether and under what conditions a new technology will be introduced. However, the development of a program to support such decision making can require considerable time and resources. An alternative is to adapt a preexisting program to the new setting. MATERIALS AND METHODS: We describe a framework for adapting the Local HTA Decision Support Program, originally developed by the Department of Surgery and Surgical Services (Calgary, AB, Canada), for use by other departments. The framework consists of six steps: 1) development of a program review and adaptation manual, 2) education and readiness assessment of interested departments, 3) evaluation of the program by individual departments, 4) joint evaluation via retreats, 5) synthesis of feedback and program revision, and 6) evaluation of the adaptation process. RESULTS: Nine departments revised the Local HTA Decision Support Program and expressed strong satisfaction with the adaptation process. Key elements for success were identified. CONCLUSION: Adaptation of a preexisting program may reduce duplication of effort, save resources, raise the health care providers' awareness of HTA, and foster constructive stakeholder engagement, which enhances the legitimacy of evidence-informed recommendations for introducing new health technologies. We encourage others to use this framework for program adaptation and to report their experiences.

Multi-criteria development and incorporation into decision tools for health technology adoption.

PURPOSE: When introducing new health technologies, decision makers must integrate research evidence with local operational management information to guide decisions about whether and under what conditions the technology will be used. Multi-criteria decision analysis can support the adoption or prioritization of health interventions by using criteria to explicitly articulate the health organization's needs, limitations, and values in addition to evaluating evidence for safety and effectiveness. This paper seeks to describe the development of a framework to create agreed-upon criteria and decision tools to enhance a pre-existing local health technology assessment (HTA) decision support program. DESIGN/METHODOLOGY/APPROACH: The authors compiled a list of published criteria from the literature, consulted with experts to refine the criteria list, and used a modified Delphi process with a group of key stakeholders to review, modify, and validate each criterion. In a workshop setting, the criteria were used to create decision tools. FINDINGS: A set of user-validated criteria for new health technology evaluation and adoption was developed and integrated into the local HTA decision support program. Technology evaluation and decision guideline tools were created using these criteria to ensure that the decision process is systematic, consistent, and transparent. PRACTICAL IMPLICATIONS: This framework can be used by others to develop decision-making criteria and tools to enhance similar technology adoption programs. ORIGINALITY/VALUE: The development of clear, user-validated criteria for evaluating new technologies adds a critical element to improve decision-making on technology adoption, and the decision tools ensure consistency, transparency, and real-world relevance.

Workshop on immunizations in older adults: identifying future research agendas.

Goals for immunization in older adults may differ from those in young adults and children, in whom complete prevention of disease is the objective. Often, reduced hospitalization and death but also averting exacerbation of underlying chronic illness, functional decline, and frailty are important goals in the older age group. Because of the effect of age on dendritic cell function, T cell-mediated immune suppression, reduced proliferative capacity of T cells, and other immune responses, the efficacy of vaccines often wanes with advanced age. This article summarizes the discussion and proceedings of a workshop organized by the Association of Specialty Professors, the Infectious Diseases Society of America, the American Geriatrics Society, the National Institute on Aging, and the National Institute of Allergy and Infectious Diseases. Leading researchers and clinicians in the fields of immunology, epidemiology, infectious diseases, geriatrics, and gerontology reviewed the current status of vaccines in older adults, identified knowledge gaps, and suggest priority areas for future research. The goal of the workshop was to identify what is known about immunizations (efficacy, effect, and current schedule) in older adults and to recommend priorities for future research. Investigation in the areas identified has the potential to enhance understanding of the immune process in aging individuals, inform vaccine development, and lead to more-effective strategies to reduce the risk of vaccine-preventable illness in older adults.

Acknowledging complexity: critically analyzing context to understand interdisciplinary research.

It is timely to develop improved understandings about strengthening interdisciplinary contexts to guide effective and quality healthcare research; contexts in which health and social issues occur do not recognize disciplinary boundaries. Similar to the notion of "partnership", the terms multidisciplinary, interdisciplinary and transdisciplinary are in danger of becoming conceptually indistinct and thus of limited usefulness for researchers, practitioners and teams. In this paper, we review basic concepts related to cross-disciplinary relationships as well as common arguments for and against interdisciplinary research. We then extend this critique by adding considerations of the influence of context, specifically social and spatial influences on interdisciplinarity. In doing so, we advocate the need for research that explicitly acknowledges complexity and considers context to advance understanding of effective interdisciplinary research.

Recombinant bovine interleukin 2 enhances immunity and protection induced by Brucella abortus vaccines in cattle.

Augmentation of immunization of cattle Brucella abortus S19 or a B. abortus soluble protein extract (SPEBA) vaccine through administration of recombinant bovine IL 2 (rBoIL 2) was evaluated. Seventy-five heifers were divided among 6 groups that were treated with the following: Group 1, no treatment; Group 2, rBoIL 2 (1microg/kg) on day 0; Group 3, SPEBA (2 mg) on day 0 and week 9; Group 4, SPEBA + rBoIL 2 on day 0, SPEBA on week 9; Group 5, S19 (10(7) CFU) on day 0 and week 9; Group 6, S19 + rBoIL 2 on day 0, S19 only on week 9. Approximately, 6 months after vaccination, cattle were bred by natural service, and at mid-gestation pregnant cattle were challenged intraconjunctivally with 9.1 x 10(5) CFU of virulent B. abortus S2308. Pre- and post-challenge antibody responses were measured by an enzyme-linked immunosorbent assay, a particle concentration fluorescence assay, and the card test. Lymphoproliferation (LP) responses to gamma-irradiated B. abortus and SPEBA antigens were measured in peripheral blood mononuclear cells. After vaccination, antibody responses to B. abortus elevated rapidly in SPEBA- and S19-vaccinates with and without rBoIL 2, however, these responses were significantly (P < 0.05) higher in vaccinates which also received rBoIL 2. Antibody levels for all vaccinated groups had returned to those of negative control groups by the challenge date with the exception of the SPEBA/rBoIL 2 group. In general, LP responses were higher in vaccinated or rBoIL 2-treated cattle than for unvaccinated controls. Challenge of 48 pregnant heifers resulted in abortions in 4/9 of Group 1, 0/9 of Group 2, 4/8 of Group 3, 2/9 of Group 4, 1/7 of Group 5, and 0/6 of Group 6 cattle. Treatment with rBoIL 2 alone (Group 2) provided significant (P < 0.05) protection from infection, abortions and induction of sero-positive status compared to untreated (Group 1) cattle. Co-administration of rBoIL 2 with S19 resulted in significant (P < 0.05) augmentation in onset, duration and magnitude of LP responses to B. abortus antigens following challenge. Characterization of the cytokine response of bovine monocyte-derived macrophages by real-time polymerase chain reaction indicated that in vitro stimulation of these cells with rBoIL 2 resulted in a profound up-regulation of genes encoding tumor necrosis factor-alpha, IL 12p40, and interferon-gamma reflecting activation of the cells. Overall, rBoIL 2-treatment was associated with fewer infections, sero-conversions and a significant (P = 0.02) level of protection against abortion as compared to vaccination alone or no treatment.

Bridging the divide between families and health professionals' perspectives on family-centred care.

OBJECTIVES: To describe and discuss key findings from a recent research project that challenge an increasingly prevalent theme, apparent in both family-centred care research and practice, of conceptualizing family-centred care as shifting care, care management, and advocacy responsibilities to families. The purpose of the research, from which these findings emerged, was to develop a conceptualization of family-centred care grounded in the experiences of families and direct health-care providers. DESIGN: Qualitative research methods, following the grounded theory tradition, were used to develop a conceptual framework that described the dimensions of the concept of family-centred care and their interrelationships, in the substantive area of children's developmental services. This article reports on and extends key findings from this grounded theory study, in light of current trends in the literature. SETTING AND PARTICIPANTS: The substantive area that served as the setting for the research was developmental services at a children's hospital in Alberta, Canada. Data was collected through focus groups and individual interviews with 37 parents of children diagnosed with a developmental problem and 16 frontline health-care providers. FINDINGS: Key findings from this research project do not support the current emphasis in family-centred care research and practice on conceptualizing family-centred care as the shifting of care, care management, and advocacy responsibilities to families. Rather, what emerged was that parents want to work truly collaboratively with health-care providers in making treatment decisions and on implementing a dynamic care plan that will work best for child and family. DISCUSSION AND CONCLUSIONS: A definition of collaboration is provided, and the nature of collaborative relationships described. Contributing factors to the difficulty in establishing true collaborative relationships between families and health-care professionals, where the respective roles to be played by health-care professionals and families are jointly determined, are discussed. In light of these findings we strongly advocate for the re-examination of current family-centred care policy and practice.

Constraints on women's intersectoral health partnerships: lessons from Canada.

Issues that constrain women's organizations from developing partnerships that promote women's health through health policy development and implementation are discussed in terms of lessons drawn from 3 studies. Key issues are the values underlying notions of partnership and participation, communication across sectors, different worldviews, and the resource limitations of feminist organizations. By attending to constraints and learning from successes and failures, women's organizations will be able to promote women's health through intersectoral partnering. The health sector and health professionals need to respond to the constraints in order to benefit from the expertise that resides within women's organizations.