Abstract
The World Health Organization (WHO) Healthy Cities (HC) projects are the best known of the settings-based approaches to health promotion. They engage local governments in health development through a process of political commitment, institutional change, capacity-building, partnership-based planning and innovative projects. Many cities have promoted HC projects in Taiwan since 2002. In 2008, the Taiwan Alliance for Healthy Cities (TAHC) was launched to assist local governments in effectively establishing, operating and promoting HC projects. In this article, we share our experiences of establishing a platform and network to promote the HC program in Taiwan. Based on individual city profiles and governance in Taiwan, the TAHC developed a well-organized framework and model to encourage strong leadership in local governments and to promote participation and engagement in their communities. In the last 6 years, leaders from Taiwan’s local governments in HC networks have integrated the HC concepts into their governance models, actively engaging and combining various resources with practical expertise and private sectors. The network of health in Taiwan allows each city to develop its unique perspective on the HC projects. Using this method, not only local government meets its needs, but also increases governance efficiency and effectiveness, resulting in the promotion of its citizens’ overall sustainable urban health development. This HC network in Taiwan has partnerships with government and non-governmental organizations (NGOs), with academic support and citizen involvement, a dynamic data collection system and demonstrated leadership in the sharing of information in the Asian region.
Keywords
Introduction
The ‘Healthy Cities’ (HC) project, proposed by the World Health Organization (WHO) in 1986, hopes to achieve “Health for All” by establishing healthy public policies and promoting health promotion programs in local areas (1). Over 5000 cities and communities have implemented HC projects worldwide, since the inception of HCs (2). Taiwan launched its HC program in 2002, which was 16 years after the WHO Regional Office for Europe launched its HC project. Unlike most countries, which rely on nonprofit organizations that are non-governmental organizations (NGOs), Taiwan’s HC program resembles those in Europe, which are enacted directly by the government, but requesting the cooperation of academic experts and NGOs.
HC projects have six common characteristics: commitment to health, political decision-making, intersectoral action, community participation, innovation and healthy public policy (3,4). In 1997, the WHO designed a three-phase, 20-step protocol for developing HC projects to promote “comprehensive and systematic policy and planning for health, and to emphasize the need to address inequality in health and urban poverty; the needs of vulnerable groups; participatory governance; and the social, economic and environmental determinants of health” (5). Consequently, the different needs among Taiwan’s regions add to differences between Taiwan’s HC program and those of Western countries. In Europe, nearly 100 cities are members of the WHO European Healthy Cities Network, encompassing 30 national HC networks and more than 1400 cities and townships as members. The primary goal of a healthy city is to put health high on the social, economic and political agenda of city government. Each 5-year phase in Europe focused on core priority themes and was launched with a political declaration and a set of strategic goals.
In Asia, the Alliance for Healthy Cities (AFHC) is an organized network of Asian cities aiming to use the HC approach and to provide opportunities for interchange of the experiences of the HC movement in Asian cities. The AFHC was founded on 17 October 2003 during the ‘First Organizational Meeting’, an inaugural meeting held at the WHO Regional Office for the Western Pacific in Manila, Philippines. The AFHC includes municipal governments, national governments, NGOs, the private sector, academic institutions and international agencies, as well as promoting the interaction of people who are at the front lines of health issues. To that end, the AFHC promotes information exchange, interactions of people, research development and capacity building programs; however, although sharing mutual experiences between Asian HC promotion programs and evaluation of performance and benefits from HC programs has been a valuable function of the AFHC, it is little known outside the region. The objective of this paper is to describe some of the experiences from the development and achievements of the HC program in Taiwan.
Method
Development and movement of Taiwan Alliance for Healthy Cities (TAHC)
Taiwan established its HC network on 20 January 2008, as a wide-reaching partnership to connect governmental departments, local administrations, experts, citizen groups, social organizations and local residents. Approximately 70 persons attended a meeting to establish the TAHC, when TAHC became an organization of representatives from 23 cities, NGOs, academia and private organizations. During this meeting, the attendees drafted and signed the ‘Protocol for Healthy Cities’, which required at least one meeting a year, beginning with informal discussion and leading later to a decision on the details of a yearly workshop, which would alternate throughout the TAHC member cities. The TAHC has three commissions and their responsibilities are divided as follows:
Research and development group: collection, monitoring and evaluation of city indicators;
Events and training group: planning for education and training relating to HC; and
Award evaluation group: planning and selecting awards for HC.
Because over 60% of Taiwanese citizens are living in metropolitan and urban areas, Taiwan’s HC strategies are uniquely urban and thus, focus on tackling major public health problems in cities. Sustainable solutions are being sought for other urban problems, integrating strategies in which the awareness of health and the solutions’ environmental implications work synergistically (6). Local government officials and departments took a leading role to integrate the voluntary and private sectors into the planning and implementation of HC strategy (7). Taiwan has witnessed an increase in cities joining the HC program, from only two cities from 2002–2005, to 44 cities or counties, NGOs and enterprises by 2014.
What opportunities motivated the HC movement in Taiwan? This was not just based on resources from the government: the TAHC was integrated and then instructed local government leaders about how to create, implement and evaluate a plan for HC and provided various mechanisms to share experiences or HC performance in local and national meetings.
Based on the reference from the WHO ‘Health 2020’ strategy, the TAHC encouraged cities in Taiwan to recognize their own and global efforts toward integrating health in all policies (8). Moreover, the TAHC organized a supporting team from domestic academia and NGO members, to accompany and guide local government leaders which resulted in teamwork on the HC program in each city. The first step, establishment of a ‘city healthy profile’ (CHP) to assess the demands or needs of the Taiwanese in cities was suggested as a HC project priority step. The CHP usually uses health indicators to define the population’s health in individual cities and to present information on lifestyles and environmental and social factors, that affect health (9). Knowing this, we set appropriate goals to allow HC programs to move forward gradually. The system of HC indicators is dynamic, making its establishment and monitoring even more important. HC indicator data can improve estimates, allow for diagnoses of overall problems and illuminate developing trends, thereby allowing the program to move forward appropriately, in both policy setting and problem solving. At the outset, these indicators were developed through dialogue among team members, citizens and program officials. Figure 1 shows how our HC profiles created the indicators of HC. After six months of discussion, the representative indicators for Taiwan’s HC program were developed from 32 indicators within the WHO international HC program (10) and domestic indicators. To express our unique local concerns, we added 15 more indicators to Taiwan’s HC profile, resulting in 47 HC indicators.
Using a ‘HC’ profile to form the indicators of HC in Taiwan.
Importantly, the HC project in Taiwan was decentralized. Each city in Taiwan followed a unique route to achieve its HC vision. The cities not only adopted different strategies, but also faced different challenges, distinctive opportunities and constraints.
An aging population and urbanization are two global trends that together comprise the major forces shaping the 21st century (11), so Taiwan has integrated resources in two programs, the HC and ‘Age-friendly City’ (AFC), using similar evidence-based models for promoting and maintaining our HC and AFC programs. Our inclusion of numerous organizations and groups stemmed from the motivation to encourage all Taiwanese participants to collaborate and share information; however, Taiwanese mayors tended to overemphasize their efforts in solving citizens’ problems, while underemphasizing the available resources at their disposal. To inspire them to work even harder for their citizens, we at the alliance leveraged their desire for notoriety. We designed a platform of formal competition and experience-sharing that would help promote their individual HC and AFC programs. Thus, competitive innovation awards for the HC or AFC projects were born, which provided a good opportunity to exchange or share the performance of HC or AFC programs with other cities. The competitions invited academic or experienced experts to judiciously evaluate their performance and then presented innovative awards at annual conferences. Participating in the awards ceremony for the HC program were: local governments, expert consultants, social groups, community organizations and individual citizens. If local government won an excellence award for HC or AFC, the mayors’ great efforts and benefits to citizens were announced in the media. To further encourage the positive impacts of HC and AFC programs, our alliance created the ‘Award for Healthy Cities and Age-Friendly Cities’. Besides helping with our plan’s extension and application, this reward inspired inter-city sharing of their findings. The TAHC offered eight awards for HC and eight awards for AFC: there were 16 categories in total for award applications, as follows:
Related to healthy cities: Health policy award (health promotion policies): governmental organizations investigate and implement public policies, including both top-down and bottom-up approaches, encouraging citizen organizations to participate and establishing public policy beneficial to the community. Healthy environment award (establishment of an environment for health promotion): Includes establishment of environments that encourage practical health habits, such as walking paths, gardens, greenery, outcrops, cultural centers, tourist areas, smoke-free environments and exercise facilities. Healthy lifestyle award (healthy living): Methods to assist citizens in engaging in a healthy lifestyle, including: obesity prevention; prevention of hyperglycemia, hyperlipidemia and hypertension; and tangible plans for healthy aging. Health sustainability award (HC sustainability through low-carbon and green energy): investigations into energy conservation and low-carbon policies, with emphasis on tangible results to share with other HC. Health industry award (culture, leisure or creative industries): exploration of these industries focused on the creation of procedures that result in encouraging healthy self-cultivation in citizens. Mental health award (mental health promotion): examination of public mental health, including cases that foster better mental and physical health, as well as suicide prevention. Emphasis is given to tangible results that can be shared with other HC programs. Health safety award (city safety): inspection of various city health circumstances, including road safety, water safety, violence prevention, physical safety, emergency care and disaster rescue. This award includes reviews of disaster prevention, preparation and recovery mechanisms that can lower the incidence of loss of life or property. Preference given to cases with tangible results that can be shared with other HC. Health equality award (health equality): inquiries into how to alleviate disparities in health equality. This category includes exploration focused on underprivileged groups and community welfare. Such programs focus on attaining health promotion for the whole community and having tangible results that can be shared with other HC.
Related to age-friendly cities: Respect for the elderly award (respect and social inclusion): the pursuit of an atmosphere of respect toward the elderly, including plans to encourage citizens to be conscious of their treatment of the elderly. Programs may focus on improving the elderly’s situation, so that they may freely participate in post-retirement work, allowing them to gain more respect in the community. Programs with tangible results that can be shared with other HC are preferred. Intimacy with the elderly award (social participation): the creation of supportive environments that improve the elderly’s aging process and lifestyle more easily, through leisure, social, cultural and self-improvement events. Family cooperation is included, and the results are tangible and possible to share with other HC. Removal of obstructions award (outdoor spaces and buildings): focusing on the needs of the elderly, women, children and people with disabilities, the improvements were made in services, so that a higher level of consideration toward these groups is apparent. This award focuses on environmental improvements, safer facilities, and the removal of obstructions in public spaces. Tangible results that can be shared with other HC are preferred. Traffic award (transportation): research into how elderly citizens move through public areas, with emphasis on public traffic and information. Projects assure better safety, comfort, movement and consideration for the elderly, especially in terms of application and hardware implementation. Results are tangible and possible to share with other HC. Safe living award (housing): studies into the comfort and safety of residential environments for senior citizens, with emphasis on reliable environments that meet service, equipment and hygiene needs. Other foci include connecting families with their communities and proper selection of healthy living environments. Tangible results that can be shared with other HC are required. Connection reward (communication and information): analysis of how elderly citizens interact with information and communication technology services, with emphasis on making these services safer and more convenient. Promotion of lifelong learning and individual knowledge is stressed. The project must have tangible results. Health award (community support and health services): research on both hardware and software that can facilitate care for the elderly. This includes establishment of multifaceted services such as volunteer services, emergency planning and health care as methods to more strongly connect the elderly to the community. Both mental and physical health predominate. Tangible results that can be shared with other HC are required. Anti-aging award (civic participation and employment opportunities): creation of work and volunteer opportunities for the elderly. Programs are encouraged for senior citizens to leave their homes for work or social activities. The ultimate goal is to raise the elderly people’s self-esteem by showing them that they have a place in society. Submissions have tangible results that can be shared with other HC.
The TAHC works through creation of a platform that encourages cooperation. When establishing a promotional plan for the HC program, TAHC creates not only a rolling education plan for members of local government, but also collects and establishes a set of HC indicators. By monitoring these indicators as local governments execute the plan, TAHC uses the values to evaluate the plan’s effectiveness. The indicators also allow for management and improvement of the plan’s policies, creating a dynamic system within the plan. In the end, such a system has triumphed in sustainability and adeptness at restarting the execution of policies. The plan required a work group to craft an integrated structure across departments and other involved parties. Through brainstorming across numerous meetings and with mutual support between the group and the organization’s director, it was believed that the plan could achieve its goal of widespread promotion. Combined understanding of citizens’ needs, the setup of indicators, the execution of the plan itself and guidance of assessments led to a standardized, rolling plan in the form of Plan, Do, Check and Action (PDCA).
Results
Achievements of the TAHC
The TAHC held an annual HC conference and award exhibition. Each city in Taiwan presented various innovative projects and performances in the HC or AFC categories. From 2008 to 2013, HC award categories created by the TAHC dropped from 11 to eight. At the same time, we introduced eight award categories for AFC. The applications for innovation awards totaled 121 in 2009 and increased to 518 in 2014 (a 3.3-fold growth) (Table 1). In addition, applications (Table 2) for HC poster awards increased from 58 in 2012, to 271 in 2014 (a 3.7-fold increase), and those for AFC poster awards increased from 40 in 2012, to 148 in 2014 (a 2.7-fold increase). From the applicants, one excellent city award for HC or AFC was selected, using a strict evaluation procedure (via field survey or documentation).
Number of innovation awards from local governments in Taiwan.
Number of posters (and awards) from local governments in Taiwan at the annual conference.
Based on the innovation awards from various topics on HC or AFC, the TAHC did not stimulate all members from local governments equally to develop positive or competitive ideas, nor thinking about HC or AFC. Leaders asked for innovative projects through effective integration of resources, and encouraging various motivations or niches, to obtain more awards the following year. The benefits of HC and AFC awards included the establishment of empirical research on specific topics, sharing and generation of innovative ideas, effective modification of previous work processes and cooperation in transdisciplinary sectors. It was an important contribution of the innovation awards to encourage various effective strategies to deal with out-of-date loading, and also to upgrade the thinking process among governors. We strove to establish steps to “imitate, improve and innovate,” for governors in each local government to help develop innovations. Some winners of innovation awards on HC or AFC have also upgraded their positions and acted as models, to share their experiences with colleagues.
Regional activities
Taiwan’s promotion of its successful projects has allowed it to obtain a strong HC reputation in the region. To help Asian cities achieve their HC goals, the Alliance for Healthy Cities (AFHC) in the Western-Pacific region is a network of international cooperation, seeking to offer an effective and efficient tool. Although the AFHC is a group of cities and other organizations working in close collaboration with the WHO, the Alliance members shared experiences with other cities only by using a biannual conference (12). By 2014, Taiwan had 22 cities in the AFHC. Despite Taiwan’s cities holding associate memberships, our members were still eager to share our HC with other Asian cities at the biannual conference. Table 3 shows Taiwan’s continuous growth in the last 3 years, an increase from 35 participants in 2010, to 110 participants in 2014 (a growth rate of 210%). In addition, our AFHC assembly’s oral presentations increased from 13 in 2010, to 17 in 2014 (a growth rate of 31%), and the poster presentations increased from 24% in 2010 to 69% in 2014 (a growth rate of 187%). Our AFHC innovation awards also significantly increased, from two cases to seven (a growth rate of 250%). These results stemmed from information disseminated at international or domestic meetings, cooperation and exchanges with other Asian cities, and the aid of individual cities’ mayors.
Numbers of participants and presentations in AFHC, from 2010 to 2014.
AFHC: Alliance for Healthy Cities.
Even though AFHC created a HC network in Western Pacific countries, limited resources or activities limited the exchange of experiences of HC for the AFHC members (13). Until 2014, three members from Mongolia, Vietnam and the Philippines were invited and supported by a private organization from Japan, to guide specific topics on the HC movement over the short-term. It has been recommended to install a HC supporting center or resources to monitor or upkeep moderators in Asian cities, through various educational or teaching programs, site visiting or case studies on HC. Under the limited circumstances of foreign affairs, Taiwan’s HC program was in full force in its efforts to engage every city in international activities.
Taiwan’s members not only attended the AFHC international biannual conference, they also engaged in exchanging experiences with other Asian cities. For example, 16 members of the TAHC visited the Japanese chapters of HC in 2013, visiting both the secretariat and the HC chapter in the cities of Kashiwa and Akita. Our members also visited Toyoshikidai’s AFC, where they observed the Sophie retirement home. These activities helped us to learn more about successful methods for AFC programs. In 2014, the TAHC secretary-general met with the Shanghai HC Alliance in China, presenting tangible results of Taiwan’s HC and AFC programs. Through this effort, Taiwan impressed Japan and China, concentrating attention on HC programs as part of an effort to encourage more cross-strait cooperation. At the same time, five members from the Alliance of HC in Hong Kong, China, including the president and general secretary, attended our 2014 HC and AFC awards ceremony. At this event, TAHC invited them to present a keynote speech and share their experiences in promoting HC and AFC programs (14).
In order to encourage innovative knowledge or strategies on HC and AFC, the TAHC invited notable scholars to organize various conferences or seminars. This knowledge flow has been a key aspect in achieving successful HC programs in Taiwan. For example, in 2004, TAHC invited two major pioneers of the world’s HC, Leonard Duhl and Trevor Hancock, to expound on their concepts of a HC. This effort has expanded how TAHC conceptualized the HC and related topics. In 2005, TAHC invited four foreign scholars from different countries (Australia, Canada, the USA and China) to share experiences from their respective HC programs. In addition, TAHC invited seven member cities of the West-Pacific HC Alliance. In total, 14 members joined this Taiwanese HC meeting. In 2010, scholars from both Australia and Korea joined the TAHC conference. TAHC invited two experts to the 2011 AFC seminar: Ruth Finklestein, who revealed results of the AFC program of New York, USA and Takiko Okamoto of Japan, who showed us the current situation in Akita’s AFC program. In both 2012 and 2014, Taiwan held the Asia-Pacific Conference on AFC and Age-Friendly Economies. TAHC invited scholars from nations worldwide to share their experiences with their HC and AFC programs (15).
Concurrently, the annual innovative HC award selection allowed us leverage, encouraging mayors and other involved individuals to attend these annual HC seminars. Besides the live sharing of knowledge that occurred, important results and innovations were documented on the dedicated website or in physical form, allowing other HC to have easy access to these data. These practices are aligned with the WHO guidelines, to promote ‘support for community-level action and capacity-building; strengthening of infrastructures and networks; and meaningful organizational development and change’ (16).
Discussion
HC are characterized by a strong commitment to community participation and empowerment (17); however, in Taiwan much work remains to combine the industrial, public, academic, civil and research sectors’ resources. This was now our foremost goal, as doing so could transform Taiwan as a whole into a healthy and age-friendly country. Gase et al. (16) indicated seven interrelated strategies for incorporating health considerations into decisions and systems:
Developing and structuring cross-sector relationships
Incorporating health into decision-making processes
Enhancing workforce capacity
Coordinating funding and investments
Integrating research, evaluation and data systems
Synchronizing communications and messaging
Implementing accountability structures
Because mayors in Taiwan are democratically elected, we designed a combination of mayoral policies and citizens’ demands to confidently promote HC and AFC programs. Hence, when mayors desire a second term, they know how to satisfy their citizens’ demands. Consequently, a city engaging in HC and AFC plans evaluates its citizens’ needs and its plans’ specific effects. Whether the city chose community forums, consensus camps, surveys, or personal appeals from the mayor, it had to confirm the issues the citizens cared about most. The city did this by integrating city and country health databases and afterward, running city-country comparisons on either qualitative or quantitative data. It also mobilized members of government, scholars and community representatives to determine the health issue or issues that take priority in the program’s drafting and planning. Because a HC plan’s purpose was to construct a healthy environment, community and populace, public opinion was essential. Understanding the public’s needs and problems shaped the direction of further analyses, which then shaped the plan’s individual, actionable steps. Only through understanding the citizens’ needs and problems could a HC program be well-organized and easily implemented (18).
Other than offering specialized knowledge to local government, we enrolled different disciplines to encourage participation in HC activities. Moreover, annual award ceremonies were held for both HC and AFC plans. These award ceremonies encouraged the participation of every city through incentives. A workshop on learning from successful plans was also held, for mutual discussion and learning. As a consequence, we believe we designed a well-organized mechanism to promote HC and AFC in local government, through the integration between the public sector, the private sector and community engagement. This was a simple protocol to build the skills or techniques of HC through the creation of a platform that encouraged cooperation or exchange. When establishing a promotional plan for the HC program, we created not only a rolling education plan for members of the local governments, but also collected and established a set of HC indicators. The indicators also allowed for the management and improvement of the plan’s policies, creating a dynamic system within the plan. In the end, we were successful in substitutability and adeptness based on PDCA model to implement various health in all policy. Such a plan required a work group to craft an integrated structure across departments and other involved parties. Through brainstorming across numerous meetings and with mutual support between the group and the organization’s director, the plan achieved its goal of widespread promotion.
In addition to actively advocating broad healthy public policies, the Taiwanese government leveraged its resources to improve accessibility and equality. One important principle was the establishment of localized health policies that could encourage citizens to participate in public policy formation. The result was an interdepartmental institution that encouraged a supportive environment for all. For example, when the government first began the HC program, it used Tainan as its pioneer city. Tainan demonstrated the HC program’s effectiveness in involving academic groups to construct a template for health promotion. This example shed light on surveys’ effectiveness in assessing citizens’ needs, the launching of multidimensional HC indicators, the references to the Ottawa Charter in developing strategies, the plan’s actual execution, its monitoring process, review of progress and the PDCA model’s practicality. Therefore, Tainan city served as a model for future HC. When other cities entered the program, they visited Tainan for study or practice (19).
Other than simply encouraging more academics and NGOs to involve themselves in HC programs, we suggested including other groups, such as citizen groups and enterprises. Through interdisciplinary discussions of HC topics, we found it easier to assist community organizations in satisfying citizens’ needs. Although the importance of government was undeniable, encouraging participation by citizen groups and private corporations was arguably more important. Through awards and other incentives, this encouragement came naturally. As an example, the Taiwanese government stimulated exercise habits in citizens, reducing the risk of chronic illnesses (20). This newly found exercise habit stemmed from the integration of citizen exercise clubs. The government also opened up public spaces, making them available for exercise. Additional health-promoting activities were established in workplaces, through certification and appraisal (21). All together, these programs reached into every facet of society to enhance public health, which led to obvious improvement in outcome and impact.
Our cities were encouraged to continuously participate in domestic and international conferences, to share their successes on HC or AFC progress. In the 2014 AFHC conference in Hong Kong, the representative from Hong Kong showed interest in Taiwan’s cloud computing health care system, expressing a desire to study firsthand how to leverage this information platform (22). Also, the Vietnamese representative requested Taiwan’s information on managing motorcycles and scooters in urban areas. Questions asked ranged from traffic and parking issues to reducing exhaust and noise pollution. Furthermore, the Malaysian representative asked the Taiwanese about the management of night markets. Of particular interest was environmental pollution and noise pollution management, as many Asian cities currently face these issues with night markets. Through active information-sharing at the AFHC conferences, we discussed resolutions to many of the current problems Asian countries face. This was a big step toward improving quality of life for citizens in the Asian region.
Although Taiwan has wholly implemented the HC and AFC programs, we were unable to maintain sustainability by supportive legislative laws or acts about HC. In addition, the central government has ceased funding the HC programs for local governments, although some cities have organized small budget amounts to continue promoting their HC program. Only a few cities have actively promoted their plans, because city officials often change, negatively influencing the sustainability of HC plans. However, many cities have integrated the steering committee of HC and AFC into a single steering organization, and have also immersed the overall plan into the mayor’s vision of a healthy city.
Even though our HC and AFC plans did employ a top-down methodology, they required to an even greater extent a bottom-up methodology. In fact, we employed both styles, allowing for a more robust mechanism. At the beginning, our HC plan met with difficulties when attempting to engage targeted communities. Although our government and engaged scholars were consistently disseminating the HC plan’s details, the citizens lacked the concept of HC. We needed to empower communities actively, to involve them in bettering their environment and to find the demonstrator communities where prioritized HC issues could be handled by enhancing organizational abilities and human resources, thereby achieving an important step toward empowering community participation. Furthermore, strategies for health impact assessment were also used to guide the governors to set priorities and to make decisions for health in all policies.
Conclusions
Although Taiwan has been involved in the HC program for only a brief period, we have witnessed a whole-hearted effort from the government, community organizations and scholars in assisting the TAHC. With early tangible results, we hope to continue to increase the innovations that our HC programs produce. Through attendance at productive events in the biannual AFHC conferences, the members in Taiwan have continuously promoted the HC program and transcended national borders to create a ‘healthy and friendly’ environment in the Asian region, allowing for active sharing of its achievements and positioning itself as a benchmark model for the world.
Footnotes
Declaration of conflicting interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.