Assessment of China’s contributions to the Regional Network for Asian Schistosomiasis and Other Helminth Zoonoses: a questionnaire survey

Background The Regional Network for Asian Schistosomiasis and Other Helminth Zoonoses (RNAS+) was established in 1998, which has developed close partnerships with Asian countries endemic for schistosomiasis and other helminthiasis in Asia. RNAS+ has provided an ideal regional platform for policy-makers, practitioners and researchers on the prevention, control and research of parasitic diseases in Asian countries. China, one of the initiating countries, has provided significant technical and financial support to the regional network. However, its roles and contributions have not been explored so far. The purpose of this study was to assess China's contributions on the supporting of RNAS+ development. Methods An assessment research framework was developed to evaluate China’s contributions 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” represents no contribution, and “10” represents 100% contribution. Participants who included their e-mail address in the 2017–2019 RNAS+ annual workshops were invited to participate in the assessment. Results Of 71 participants enrolled, 41 responded to the survey. 37 (37/41, 90.24%) of them were from RNAS+ member countries, while the other 4 (4/41, 9.76%) were international observers. Most of the respondents (38/41, 92.68%) were familiar with RNAS+. Respondents reported that China’s contributions mainly focused on improving capacity building, providing funding support, coordination responsibility, and joint application of cooperation programs on RNAS+ development. The average scores of China’s contributions in the above four fields were 8.92, 8.64, 8.75, and 8.67, respectively, with an overall assessment score of 8.81 (10 for a maximum score). The challenge of RNAS+ included the lack of sustainable funding, skills, etc. and most participants expressed their continual need of China’s support. Conclusions This survey showed that China has played an important role in the development of RNAS+ since its establishment. This network-type organization for disease control and research can yet be regarded as a great potential pattern for China to enhance regional cooperation. These findings can be used to promote future cooperation between China and other RNAS+ member countries.


Background
Schistosomiasis, a serious infectious disease caused by blood flukes, occurs in a total of 78 endemic countries worldwide [1]. 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, Myanmar, and so on [2,3]. To achieve the goal set by the United Nations in the 2030 Agenda for Sustainable Development Goals (SDGs) of eliminating schistosomiasis by 2030, a comprehensive, multi-sectoral, and multifaceted approach across countries is needed to control, and eventually eliminate, the disease in Asia [4,5].
Efforts were made to initiate a collaboration between national research institutions and research groups within and outside Asian countries 20 years ago [6,7]. 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 first workshop of the RNAS network in the Philippines in 2000 [2], which aimed at uniting intersectoral, interregional, and international collaborations for multidisciplinary organizations (human medicine and veterinary medicine) and experts (researchers, practitioners, and policy-makers) in various fields from Asian disease endemic countries. The initiating areas of work included collaborative research, surveillance, and control of schistosomiasis in Asia, and the network also advanced the technology for the control of Schistosoma japonicum [8,9]. In the fifth RNAS workshop in 2005, its focus was expanded from schistosomiasis to include other diseases and conditions, including cysticercosis, clonorchiasis, opisthorchiasis, paragonimiasis and fascioliasis, caused by helminthiasis treatable with praziquantel, thus forming the Regional Network for Asian Schistosomiasis and Other Helminth Zoonoses (RNAS + ) of what is today [2,10,11].
The developmental pathway of RNAS + started with only two countries (China and the Philippines) in 2000 [2,4]. 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 [2,4]. Up to date, over 90% of research institutions and disease control organizations working on schistosomiasis in the 11-member countries have participated in RNAS + activities [2,12].
After two-decade operation, the RNAS + has mainly been devoted to the following four areas. First, an operational mode was developed for operating the RNAS + [11,13]. An executive committee was formed to manage the RNAS + , which is composed of a chairman, a vicechairman, several executive members, and several international observers. A rotating chairman system was adopted to elect the chairman. Second, a mechanism for information exchange and dissemination was developed by annually hosting academic workshops and training courses [12]. To date, 20 workshops have been held in different member countries, which have contributed to improved neglected tropical diseases (NTDs) control programs in the member countries [2]. Third, some multi-country cooperative research projects have been implemented, through which scientists from different countries have learned from one another to improve their relevant technologies for the application of serodiagnostics, ultrasound examination, mollusciciding, and surveillance response systems [14,15]. Fourth, capacity building has been improved by more than a dozen of training courses in the field of diagnosis, molecular biology, geographic information systems, and ethical issues, specifically desingned for the young generations of the member countries [4,16].
Some studies assessed the performance and improvement on health system, capacity building, quality management, health technology [17][18][19][20], and so on. However, no published work can be found on the assessment of the contributions of any member country in regional networks on disease prevention and control. After a literature review, a qualitative study was conducted by Furnival et al.(2018) to assess the capacity improvement of six UK healthcare organizations, using semistructured interviews, policy documents, and assessment reports as their data sources [17]. 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) [18]. A scoring criteria were developed to assess the quality of program theory [19]. A systematic review was used to evaluate the screening performance of maternal serum and ultrasound markers in detecting Down syndrome [20]. Moreover, methods for assessing the contributions of one country to a network to which it belongs are scant. Some researchers have recently explored a method to assess in-kind contributions in a donorfunded health capacity-building program in Africa, which estimates the monetary value of those contributions [21].
RNAS + celebrated its 20th anniversary in 2018 in Shanghai, China [2]. Although China along with other member countries have provided great technical and resource support on the RNAS + development, China's roles and contributions have not been explored systematically. This study aimed to perform an assessment of China's roles and contributions in the developmental pathway of RNAS + .

Research design
In this study, an assessment research framework was planned to assess China's contributions 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 on improving skills for scientists from RNAS + member countries, (ii) funding support-sponsoring the activities of RNAS + , (iii) coordination-responsibility 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, several corresponding quantitative indicators were formed. In addition, to obtain the direct value of China's contributions to this network, a score sheet on the above topics as well as for the overall contribution were created with scores ranging from "0" to "10." The higher the score, the greater the contributions.

Questionnaire and data collection
An anonymous and web-based questionnaire on the above assessment research framework was designed as an assessment tool for evaluating China's contributions to RNAS + . Three senior professionals of RNAS + provided inputs 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 on China's contributions 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 in the future. The questionnaire was used to collect the assessment information, and participants who frequently attended the recent RNAS + annual workshops were invited to participate in this survey.
This web-based survey was distributed 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 gave a score 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 was also asked to send the link to their colleagues or friends who attended the RNAS + annual workshops. The participants were asked to complete the questionnaire for once if they had attended more than one meeting.

Data analysis
All original data of this web-based questionnaire were downloaded as a .sav file format from the back-stage management platform. Because all the questions in the web-based questionnaire were required, all the data were compliant with the integrity verification 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 classified 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 contributions to RNAS + According to the survey, every participant gave a score to assess China's contributions to RNAS + ( Table 3). The average score for the overall assessment of China's contributions 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 for maximum score).

China's contributions in improving capacity building of RNAS +
According to the survey, four RNAS + annual training courses were held in China. In addition, 7 (17.07%) respondents had attended the short-time training in China, including on snails control and schistosomiasis diagnosis skills. A total of 38 (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) (Fig. 2).
China's funding contributions to RNAS + Most respondents (73.17%) had received China's grants to attend RNAS + annual workshops, and 26.83% (11/41) had received more than 5 times. In addition, China also sponsored the annual workshops held outside of China. Most respondents (70.73% ) attended the RNAS + annual workshops mainly sponsored by China but held outside of China for more than once. Among respondents, 34.15% (14/41) said that China provided grants to support the annual workshops held outside of China at least 5 times.   First, the most important challenge of RNAS + was lack of the sustainable financial 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 aspects, such as the emerging and re-emerging disease control as well as the multicountry collaborations among scientists and control authorities also need to be supported. Third, how to enhance the impact of this network and improve interregional conflicts are important issues that should be addressed.

Discussion
China, as one of two founding countries, has been actively engaged in the development of RNAS + . This paper offers a direct method to assess China's contributions to the development of RNAS + . In this survey, through the scoring method, most participants gave a high score on China's contributions to the development of RNAS + . This means that those participants agreed that China made great contributions and played an important role in the development of RNAS + . Combined with this survey and the literature review, Chinese contributions to the RNAS + development can be concluded in several ways: (i) promoting fundraising, capacity building, and coordinating the affairs at the annual workshops and training courses organized by RNAS + [4,22]; (ii) sharing important experiences on China's achievements on schistosomiasis and other parasitic diseases control [23,24]; (iii) actively promoting the routine running of RNAS + activities, including agenda setting and workshop reports [25]; (iv) directly participating in the training courses on instructions for schistosomiasis diagnosis, spatial informatics and others [4,12]; (v) establishing and updating the RNAS + website [26]; and (vi) playing the leading role in project cooperative studies, such as IDRC projects [27,28], ultrasound diagnosis of S. japonicum infection [29], and epidemiological study on control strategy of schistosomiasis and liver fluke, and so on [24,30]. A special issue was published to introduce the origin, progress, outcomes, challenges, and the way forward for the RNAS + in the past 20 years [2, 4, 13-16, 31, 32]. RNAS + has been operating as a platform for sharing  information to enhance multi-country, multi-diseases, and multidisciplinary collaboration in the Asian region. As a result of the highly collaborative projects among member countries, RNAS + has promoted the understanding of various aspects of schistosomiasis and other diseases, and emphasized that an integrated control approach can be established to eliminate the disease through intersectoral collaboration. On this issue, China's contributions have also been affirmed on the four parts, such as capacity building [13], funding support [13], coordination [2,15], and cooperation program [4,[14][15][16], of the development of RNAS + . Additional challenges identified in the survey for the RNAS + mainly focused on sustained funding, as well as research grants, which have also been reflected in recent RNAS + publications [32]. RNAS + has no sustainable funding by itself, nor fixed support from any large-scale transnational cooperation programs, indicating huge lack of financial support, and this has been confirmed by most respondents who mentioned the necessity to increase financial 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 are also the challenges. Undoubtedly, more donors are needed to assist the network in its current and future activities [31].
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 [33,34], China should continually share its experiences to enhance cooperation within member countries as an important matter listing in the profile agenda [35,36]. Second, due to the need for capacity building by RNAS + members, China can continue to support annual workshops and technical trainings as well as collaborative research activities [37,38]. Third, China can motivate more institutions and international organizations to join and enlarge the institutional coverage of RNAS + . Fourth, 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 specific region can also refer to this mode of networking for regional cooperation [39].
To our knowledge, this is the first attempt of an assessment on China's contributions in regional networks, using an assessment questionnaire with the quantitative indicators in combination 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 bias 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, e.g. RNAS + .

Conclusion
This survey showed that China has played an important role in the development of RNAS + network since its establishment in the fields of capacity building, funding support, coordination, and cooperation programs. China has effectively shared experience and provided professional support on technologies and resources to member countries during the past 20 years. The challenges of RNAS + includes lack of sustainable funding, less research activities, few new skills promoted, and lower impacts at global level. China's continual support is 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 findings can be used to promote future cooperation between China and other RNAS + member countries.