Assessment of China's Contribution in Regional Network for Asian Schistosomiasis: a questionnaire survey

Background: The Regional Network for Asian Schistosomiasis and other Helminth Zoonoses (RNAS+) launched in 1998, has close partnerships with countries endemic for schistosomiasis and other helminthiasis. RNAS+ has provided an ideal regional platform for policy-making, control, and parasitic diseases research experts in Asian countries. China, one of the initiating countries, has provided signi�cant technical and �nancial support to the regional network. Although Chinese institutions and other member countries provided great technical and resource support in RNAS+ development, China, and Chinese scientists or institutions’ contributions, have not been evaluated systematically. This study assessed Chinese contributions toward supporting RNAS+ development. Methods: An assessment research framework was planned to evaluate China’s contribution to RNAS+ in four aspects, including capacity building, funding support, coordination, and cooperation. An anonymous web-based questionnaire was designed to acquire respondents’ basic information, and information on China’s contributions, challenges, and recommendations for RNAS+ development. Each participant scored from 0 to 10 to assess China’s contribution: “0” no contribution, and “10” 100% contribution. Participants who included their e-mail address in the 2017 - 2019 RNAS+ annual workshops were invited to participate the assessment.


Background
Schistosomiasis, a serious infectious disease caused by blood ukes, occurs in a total of 78 endemic countries worldwide [1].Oriental schistosomiasis has been endemic in Asia with the rst report in the early 1900s in China [2].Until now, except in Japan where the disease has been eliminated, other Asian endemic countries are still at risk of transmission, including China, the Philippines, Indonesia, Laos, Cambodia, Malaysia, and Myanmar [3][4].To achieve the goal set by United Nations in the 2030 Agenda for Sustainable Development Goals (SDGs) of elimination of schistosomiasis by 2030, a comprehensive, multi-sectoral, and multifaceted approach across countriesis is needed to control, and eventually eliminate, the disease in Asia [5][6].
Efforts were made to initiate a collaboration between national research institutions and research groups within and outside Asian countries 20 years ago [7][8]].The Regional Network on Asian Schistosomiasis (RNAS) was originated during a discussion session at an international workshop held in China in 1996, and was planned to build a formal network during another international seminar in China in 1998.RNAS was formally established during the rst workshop of RNAS network in the Philippines in 2000 [3], and aimed at uniting intersectoral, interregional, and international collaborations for multidisciplinary organizations (human medicine and veterinary medicine) and experts (researchers, scholars, and policymakers) in various elds from Asian disease endemic countries.The initiating areas of work included collaborative research, surveillance, and control of schistosomiasis in Asia, the network also advanced the technology for the control of Schistosoma japonicum (S. japonicum) [9][10].In the fth RNAS workshop in 2005, its focus was expanded from Schistosomiasis to include other conditions, including cysticercosis, clonorchiasis, opisthorchiasis, paragonimiasis and fascioliasis, caused by helminthiasis treatable with praziquantel, thus giving rise to the Regional Network for Asian Schistosomiasis and Other Helminth Zoonoses (RNAS+) [3,[11][12].
The developmental pathway of RNAS+ was from a small start with only two countries(China and the Philippines) in 2000 [3,5].Since then, its members have gradually increased to 11 countries (China, the Philippines, Cambodia, Indonesia, Laos, Thailand, South Korea, Japan, Vietnam, Myanmar, and Malaysia), in 2018 [3,5].Statistically, over 90% of research institutions and disease control organizations working on schistosomiasis in the 11-member countries have participated in RNAS+ activities [3,13].
After a two-decade operation of RNAS+, its major achievements are re ected in the following four areas.
First, an operational mode was developed for RNAS+ [12,14].The executive committee, with its responsibility of speci cally managing the RNAS+, composed of a chairman, vice-chairman, several executive members, and several international observers (assumed to be representatives of other member countries and international organizations), was formally formed.A rotating chairman system was adopted to elect the chairman.Second, the approach to RNAS+ information exchange and dissemination that was developed was to host annually academic exchange workshop and training courses [13].To date, 20 workshops (including the web-based 20 th RNAS+ workshop held in Shanghai on October 22, 2020) were held in different member countries, which has led to improved national neglected tropical diseases (NTDs) control programs [3].Third, some multi-country cooperative research projects were implemented through which scientists from different countries learned from one another to improve their relevant technologies for the application of serodiagnostics, ultrasound examination, mollusciciding, and surveillance response systems [15][16].Fourth, capacity building was improved by more than a dozen training courses in the eld of diagnosis, molecular biology, geographic information systems, and ethical issues that were arranged among member countries' younger generations [5,17].Some studies assessed the improvements and performances in capacity building [18], the health system [19], quality management [20], health technology [21], and so on.However, no published work exists on the assessment of the contribution of any member country in those regional networks on disease control.After a literature review, we found a qualitative study that assessed the improvement capacity of six UK healthcare organizations, using semi-structured interviews, policy documents, and assessment reports as their data sources [18].A self-assessment questionnaire proposed by the World Health Organization (WHO) was used to assess the quality of the Estonian health system and comprised four domains (policy, organization, methods, and resources) [19].The scoring criteria were developed to assess the quality of program theory [20].A systematic review was used to evaluate the screening performance of maternal serum and ultrasound markers in detecting Down syndrome [21].Limited methods exist for determining the contributions of one country to a network to which it belongs.Researchers have recently offered a method to determine in-kind contributions in a donor-funded health capacity-building program in Africa, which estimates the monetary value of those contributions [22].
Although Chinese institutions along with other member countries provided great technical and resource support toward the RNAS+ development, China's role and Chinese scientists or institutions' contributions have not been evaluated systematically.This study aimed to perform an assessment of China's contribution and role in the developmental pathway of RNAS+ through a case study approach along with a questionnaire survey using several quantitative indicators and scoring tables.

Assessment setting
In this study, we designed an assessment research framework to evaluate China's contribution according to the four major achievements of RNAS+ in the past 20 years.This framework covers the following four topics: (i) capacity building-providing opportunities for improving skills of scientists from RNAS+ member countries, (ii) funding support-sponsoring of the activities of RNAS+, (iii) coordinationresponsibility for the operation and development of RNAS+, and (iv) cooperation programs-initiating the application of multi-country joint collaborative projects in Asia.For each topic, we designed several corresponding quantitative indicators.In addition, to obtain the direct value of China's contribution to this network, we created a score sheet on the above topics as well as for the overall contribution with scores ranging from "0" to "10."The higher the score, the greater the contributions.

Questionnaire and data collection
We designed an anonymous, web-based questionnaire on the above assessment research framework as an assessment tool for evaluating China's contribution to RNAS+.A questionnaire survey was used to collect the assessment information, and participants who frequently attended the recent RNAS+ annual workshops were invited to participate in this survey.Participants were required to complete the questionnaire just once even if they attended more than one meeting.
Three senior professionals of RNAS+ provided input to the content of the questionnaire and revised it, before the formal survey.This questionnaire had three parts: (i) general information of the participants; (ii) the core of the evaluation, China's contribution to RNAS+ (Table 1), contained quantitative indicators and scoring tables on capacity building, funding support, coordination, cooperation program, and overall assessment, from the evaluation framework; and (iii) challenges and suggestions for RNAS+ development.
We distributed this web-based survey by e-mail to the participants who provided their e-mail address during the three recent RNAS+ annual workshops from 2017 to 2019.Each participant indicated a value for his/her understanding of RNAS+; the higher the value, the more familiar they were with RNAS+.In order to encourage the participants to complete the questionnaire, two reminders were sent to each participant who were also asked to send the link to their colleagues or friends who attended the RNAS+ annual workshops.

Data analysis
All original data of this web-based questionnaire were downloaded as a .savle format from the backstage management platform.Because all the questions in the web-based questionnaire were required, all the data were compliant with the integrity veri cation requirements.Data analysis was performed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY., US).Frequency and related percentage were reported to describe classi ed variables.The arithmetic average was reported for continuous variables, as well as a bar chart to present the numerical distributions.Highcharts were used to analyze the open-ended questions.
The overall assessment of China's contribution to RNAS+ According to the survey, every participant gave a score to indicate China's contribution to RNAS+ (Table 3).The average score for the overall assessment of China's contribution to RNAS+ was 8.81 (10 maximum score).The average score of China's contributions to the improvement of capacity building, funding support, coordination, and the application of cooperation projects in RNAS+ were 8.92, 8.64, 8.75, and 8.67 respectively (10 maximum score).
China's contribution in improving capacity building of RNAS+ According to the survey, four RNAS+ annual training courses were held in China.In addition, 7/41 (17.07%) respondents had attended the short-time training in China, including on snails control and schistosomiasis diagnosis skills.A total of 38/41 (92.68%) participants indicated that they had learned useful skills from training activities held in China, and the top three were control strategy, diagnosis, and geographic information system (GIS) (Figure 2).China's funding contribution to RNAS+ Most respondents, 73.17% (30/41) had received China's grants to attend RNAS+ annual workshop, and 26.83% (11/41) had received more than 5 times.In addition, China also sponsored the annual workshop not held in China.Most respondents, 70.73% (29/41) attended the RNAS+ annual workshop mainly sponsored by China but not held in China for more than once.Among respondents, 34.15% (14/41) said that China provided grants to support the annual workshop not held in China at least 5 times.

Challenges and suggestions for RNAS+ development
From the survey, the challenges faced by RNAS+ (Figure 3) and bits of advice on what China should do in future (Figure 4) are summarized as follows.First, the most important challenge of RNAS+ was the lack of the sustainable nancial support, and more than half of the participants (26/41) mentioned the word "funding" in the open-ended question.Second, some participants pointed out that there were some challenges with the research and diagnosis skills that need to be addressed on NTDs in the region.Other areas, such as the emerging and re-emerging disease control as well as the multi-country collaborations among scientists and control authorities also need to be supported.Third, how to enhance the impact of this network and improve interregional con icts are important issues that should be addressed.Regarding China's future contribution to RNAS+ development, most of the participants indicated that it is essential for China to continue her support in the following ve areas: funding, research and technology, capacity building, and RNAS+ annual workshops as well as in training activities.In the future, the participants proposed that China should continually share in the work experience and resources, jointly apply bilateral/multilateral partnership projects with member countries, and expand more members and international agencies to RNAS+, to strengthen the operation of the network.

Discussion
RNAS+ celebrated its 20th anniversary in 2018 in Shanghai, China [3].Since 2000, a total of 20 annual workshops have been organized in China, the Philippines, Cambodia, Laos, Indonesia, South Korea, Vietnam, Thailand, and Myanmar.The number of professionals and medical and health administrative staff that have participated in RNAS+ annual workshops or training courses are a total of 1,099 persontime from 2000 to 2016 [13].Now, RNAS+ has 11 member countries and occupy the main part of the economic circle in Northeast Asia and the Association of Southeast Asian Nations (ASEAN), with a population of about 2 billion.
China, as the founding country, has been actively engaged in the development of RNAS+.This paper offers a direct method to assess China's contribution to the development of RNAS+.In this survey, through the scoring method, most participants gave a high score on China's contribution to the development of RNAS+.This means that those participants agreed that China made great contributions and played an important role in RNAS+.Combined with this survey and the literature review, we concluded that China has contributed to the RNAS+ development in several ways by: (i) promoting fundraising, capacity building, and coordinating the affairs at the annual workshops and training courses organized by RNAS+ [5,23]; (ii) sharing important experiences on China's achievements on schistosomiasis and other parasitic diseases control [24][25]; (iii) actively promoting the routine running of RNAS+ activities, including agenda setting and workshop reports [26]; (iv) directly participating in the training courses on instructions for schistosomiasis diagnosis, spatial informatics and others [5,13]; (v) establishing and updating the RNAS+ website [27]; and (vi) playing the leading role in project cooperative studies, such as IDRC projects [28][29], ultrasound diagnosis of S. japonicum infection [30], and epidemiological study on control strategy of schistosomiasis and liver uke, and so on [31][32].
A special issue was published to introduce the origin, progress, outcomes, challenges, and the way forward for the RNAS+ in the past 20 years [3,5,[14][15][16][17][33][34].RNAS+ is setting up a platform for sharing information to enhance multi-country, multi-disease, and multidisciplinary collaboration in the Asian region.As a result of the highly collaborative projects among member countries, RNAS+ promotes the understanding of various aspects of schistosomiasis and other diseases, and emphasizes that an integrated control approach can be established to eliminate the disease through intersectoral collaboration.On this issue, China's contribution is also a rmed on the four parts, such as capacity building [14], funding support [14], coordination [3,16], and cooperation program [5,[15][16][17], of the development of RNAS+.
Additional challenges identi ed in the survey for the RNAS+ were majorly re ected on sustained funding, as well as research grants, which is also indicated in the latest RNAS+ publications issue [34].RNAS+ has no sustainable funding by itself as well as no xed support from any large-scale transnational cooperation program.This indicate a huge lack of nancial support, and most respondents mentioned that there is need to increase nancial support.Moreover, RNAS+ inspired research and cooperation projects are limited, and continuous skills and programs are needed to combat NTDs and emerging parasitic diseases in this region.Additionally, how to improve the impact of the network and how to deepen the cooperation is also a challenge.Undoubtedly, more donors are needed to assist the network in its current and future activities [33].
Several ways to enhance China's contribution to RNAS+ development in the future were suggested.First, China has made great progress in schistosomiasis control in the past 70 years [35][36], China should continually share its experiences to enhance cooperation within member countries as an important matter [37][38].Second, due to the need for capacity building by RNAS+ members, China can continue to support annual workshops and technical training as well as collaboration research [39][40].Third, China can motivate more institutions and international organizations to join and enlarge the institutional coverage of RNAS+.In addition, the practice of RNAS+ suggests that establishing a network-type organization is a good approach, therefore, in addition to schistosomiasis and NTDs, other diseases requiring particular control with joint efforts in one speci c region can also refer to this mode of networking for regional cooperation [41].
To our knowledge, this is the rst attempt of an assessment of China's contribution in regional networks, using an assessment questionnaire with the quantitative indicators with four parts and scoring method.This is only one possible attempt to assess the contribution in the network.However, there are some limitations to this survey.Most of all, the number of participants is limited, and no responses were received from Japan and South Korea, which are two member countries of RNAS+, thus, the results may not represent those of all experts from all member countries.Moreover, this assessment was not carried out by an independent third party, which may have affected the results' explanation to some extent.
However, this survey has valuable reference on the role of China in the development of regional cooperation networking.

Conclusion
This survey showed that China plays an important role in the development of RNAS+ networking in the elds of capacity building, funding support, coordination, and cooperation programs.China has effectively shared experiences and provided professional support on technologies and resources for member countries during the past 20 years.The challenges of RNAS+ included lack of sustainable funding, research, skills, and impacts.China's support is continually needed, especially in organizing annual workshops, capacity building, and cooperative research.The network-type organization, of RNAS+, which focuses on the cooperation for disease control and research, can yet be regarded as a great potential pattern for China to enhance regional cooperation.Thus, the research ndings can be used to promote future cooperation between China and other RNAS+ member countries List Of Abbreviations RNAS+: Regional Network for Asian Schistosomiasis and other Helminth Zoonoses; RNAS: Regional Network on Asian Schistosomiasis; SDGs: * The scores indicated by the respondents about China's contribution to RNAS+ from the questionnaire, "0 score" meant no contribution, "10 score" indicated 100% contribution, the higher the score, the more important is China's contribution to RNAS+.
** Average score: the sum of all scores marked by the respondents / the total number of respondents.
# N(%): the number of respondents by each score (the number of respondents by each score/total number of respondents × 100%).

Figures
Figure 1 The participants understanding of RNAS+ (the understanding values ranged from 0 to 100%, "0" represented no understanding of RNAS+, "100%" represent complete understanding of RNAS+.The higher the value, the better the understanding of RNAS+)   The fastcharts of bits of advice regarding China's future role in RNAS+ development according to the survey participants China's contribution to the coordination of RNAS+ NIPD was one of the two institutions participating in the RNAS+ initiative.Chinese experts played important roles in the initiation and scale of the network.Up to now, two out of 5 experts had served as chairmen of RNAS+, 53.66% (22/41) of the respondents had invited/coordinated with China as instructors in the RNAS+ training courses or as the speaker at the annual workshops.China established the RNAS+ website and is responsible for website maintenance and information updates, while 68.29% (28/41) of the respondents know the address of the RNAS+ website.China's contribution to the application of cooperation program / project jointly run with RNAS+ member institutions NIPD, along with national research institutes of the Philippines, Laos, Cambodia, and other countries, jointly applied and received two rounds of funds from the International Development Research Center (IDRC), 36.59%(15/41) of the respondents attended this IDRC project.Most respondents, 82.93% (34/41) are willing to apply the new "Belt & Road Initiative"-related program with Chinese experts in the future.

Figure 2 Skills
Figure 2

Figure 3 The
Figure 3

Table 1 .
Sustainable Development Goals; NTDs: Neglected Tropical Diseases; S. japonicum: Schistosoma japonicum; WHO: World Health Organization; NIPD: National Institute of Parasitic Diseases; China CDC: Chinese Center for Disease Control and Prevention; GIS: Geographic Information System; IDRC: International Development Research Center; ASEAN: Association of Southeast Asian Nations .Assessment framework of interview questions RNAS+, Regional Network for Asian Schistosomiasis and other Helminth Zoonoses; IDRC, International Development Research Centre

Table 2 .
Characteristics of the survey respondents

Table 3 .
Assessment score of China's contributions to RNAS+ by survey respondents