Policy-practice gaps and barriers to the effective management of insecticide resistance in Tanzania

Policy-practice gaps and barriers to the effective management of insecticide resistance in Tanzania | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Policy-practice gaps and barriers to the effective management of insecticide resistance in Tanzania Hamenyimana E. Gervas, Irene R. Moshi, GloriaSalome G. Shirima, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8439202/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Malaria control gains are stagnating or reversing, in part due to widespread insecticide and drug resistance, as well as increasing financial and implementation challenges. This study assessed the national strategies for insecticide resistance monitoring and management in Tanzania to identify key barriers and misalignments between policy and actual practice. Methods We initially reviewed technical documents from Tanzania’s National Malaria Control Programme (NMCP) produced between 2014 and 2024, along with World Health Organization (WHO) guidelines and reports on insecticide resistance monitoring and management. This was followed by in-depth interviews with key informants in Tanzania, including policymakers, representatives from funding agencies, technical experts, scientists, and vector control implementers at district and regional levels. The qualitative data was analyzed thematically using NVivo software. Findings The document review revealed strong policy alignments of the NMCP strategies for monitoring and management of insecticide resistance with international practice as recommended by WHO. However, implementation of the policy intentions remained limited, with resistance monitoring being conducted in only 22 of Tanzania’s 184 district councils. Interviews with 24 stakeholders highlighted significant gaps between the stated policies and guidelines and the actual practice. These gaps were driven by inadequate financing, donor dependence, insufficient coordination and dissemination of guidelines, limited technical capacity, and weak engagement of communities and district-level operators. Participants emphasized that without strengthened surveillance systems, sustainable local financing, and greater community and intersectoral collaboration, achieving the current strategic goal of malaria elimination by 2030 remains unlikely. Conclusion Despite strong policy alignment and strategic planning, Tanzania's implementation of insecticide resistance management remains limited. Bridging these persistent policy-practice gaps is essential for more effective malaria vector control, and will require sustained financing, strengthened coordination, improved vector monitoring, and enhanced community and intersectoral engagement. Background Although malaria is preventable and treatable, it remains a major health challenge in Africa, disproportionately affecting the poor and marginalized populations [ 1 ]. Despite substantial progress driven by interventions such as insecticide-treated nets (ITNs), indoor residual spraying (IRS), effective diagnosis and treatment, preventive therapies, and more recently, vaccines [ 2 – 8 ], this progress has slowed, and in some areas stalled or even reversed [ 1 , 9 ]. This stagnation is driven by multiple factors, including rising commodity costs amid dwindling resources, increasing insecticide and drug resistance, inadequate adherence of the affected population to the interventions, and suboptimal intervention coverage, underscoring a widening gap between current progress and the global malaria control targets [ 3 ]. In Tanzania, malaria vector control has historically been predominated by insecticide-based approaches complemented with environmental sanitation [ 10 – 13 ]. For decades, these efforts were organized through local health systems, until the National Malaria Control Programme (NMCP), established in 1990 [ 10 , 14 ], began reinforcing nationally coordinated and regional initiatives [ 10 , 13 ]. From the early 1990s, ITN delivery strategies were piloted in Bagamoyo and Kilombero, leading to nationwide ITN scale-up starting in the late 1990s [ 10 , 14 ]. IRS was relaunched in 2007, initially covering two districts and later expanding to 18 councils in three regions of the north-west and Lake zone, using pyrethroids at first, followed by bendiocarb, and from 2014 onward, organophosphates [ 10 , 14 – 16 ]. However, in 2020, IRS was done in only six districts with the highest malaria burden regions in the same zone [ 17 ]. Over 60 million ITNs were distributed between 2009 and 2020, with continued large-scale distribution through antenatal care and immunization programs, schools, and mass campaigns [ 10 , 14 ]. Because of these efforts, and the expanded case management [ 18 , 19 ], malaria prevalence among children fell from 14% in 2016 to 7.5% in 2017 [ 10 , 18 , 19 ], but unexpectedly reversed to 8.1% in 2022, with the highest rates exceeding 15% in the Lake, Western and Southern Zones [ 18 , 19 ]. This coincided with the expansion of pyrethroid resistance, with the proportion of sentinel sites showing evidence of resistance increasing from 0% in 2004 to over 80% by 2020 [ 17 , 20 ]. This widespread pyrethroid resistance among Anopheles mosquitoes poses a major challenge to the effectiveness and long-term sustainability of pyrethroid-based vector control programs in Tanzania, threatening progress toward malaria elimination [ 21 – 23 ]. Tanzanian public health authorities have made several efforts to address these insecticide resistance challenges, aligning with global and regional practices [ 24 – 29 ]. The NMCP strategic plans and guidelines have consistently included actions to manage insecticide resistance, informed by both local evidence and international recommendations [ 10 , 17 , 30 ]. These frameworks serve as implementation roadmaps, emphasizing strategies such as insecticide rotation for IRS, combined use of ITNs and IRS with different active ingredients, the application of insecticide mixtures and mosaics to enhance vector control [ 10 , 30 – 32 ], and more recently the deployment of new generation ITNs that include either insecticide synergists or multiple active ingredients [ 2 , 3 , 32 ], and the scale-up of larval source management (LSM) across the country [ 10 , 33 ]. Despite well-structured plans, implementing interventions to achieve targeted goals has historically been challenging [ 10 , 26 , 30 ], with success requiring context-specific strategies and solutions unique to Tanzania. For instance, delays in ITN distribution reported in strategic plans [ 10 , 30 ] are not simply due to negligence or a lack of commitment; rather, they underscore the inherent difficulty in translating strategic goals into effective implementation. Critical questions remain about the discrepancies between insecticide resistance monitoring and management (IRM) policies and their on-the-ground implementation, the barriers hindering effective IRM strategies, and the resulting constraints on malaria elimination efforts. Consequently, Tanzania's prospects for achieving nationwide malaria elimination in the near future remain uncertain. This current study aimed to critically assess the national strategies for insecticide resistance monitoring and management in Tanzania, with the objective of identifying key barriers and misalignments between policy and actual practice. To achieve this, we used a combination of an in-depth review of key technical documents underpinning IRM practices in Tanzania and internationally, alongside an analysis of the opinions and perspectives of key stakeholders in vector control activities in the country. Methods Study design Document review This study was conducted between February and November 2024 and commenced with a comprehensive document review aimed at assessing national and international policies, strategies, and guidelines on insecticide resistance monitoring and management (IRM) over the past decade (2014–2024). The review focused on documents produced by Tanzania’s NMCP, the Ministry of Health (MoH), the World Health Organization (WHO) and malaria control partners. The identification was done through systematic searches of the government and WHO official websites, complemented by searches in PubMed, Google Scholar databases and other scientific repositories. Search terms included combinations of keywords such as “malaria vectors”, “insecticide resistance,” “vector control”, “insecticide resistance management,” “insecticide resistance monitoring” and “entomological surveillance”. Eligible documents included national reports, strategic plans, guidelines, frameworks, and evaluation documents relevant to malaria vector control and resistance management. For WHO documents, those published before 2010 were excluded. Key national policy documents were retrieved from the MoH and NMCP websites, including two NMCP Strategic Plans (2014–2020 and 2021–2025) [ 10 , 30 ], the Integrated Vector Management Guidelines and Standard Operating Procedures (IVM-SOP) [ 32 ], the National Guidelines for Integrated Malaria Vector Control (NGIMVC) [ 34 ], the Malaria Surveillance, Monitoring and Evaluation Plan (MSMEP) [ 35 ], and the National Strategy for Vector Control 2019–2024 (NSVC) [ 36 ]. Searches of WHO databases and scientific repositories identified several complementary global publications, including the Global Plan for Insecticide Resistance Management in Malaria Vectors (GPIRM) [ 31 ], the Manual for Monitoring Insecticide Resistance in Mosquito Vectors and Selecting Appropriate Interventions [ 37 ], the Global Report on Insecticide Resistance in Malaria Vectors [ 38 ], and the Framework for a National Plan for Monitoring and Management of Insecticide Resistance in Malaria Vectors [ 39 ]. The full list of documents reviewed is included in Table 1 . Table 1 List of documents reviewed to understand current policies, guidelines and practices of insecticide resistance monitoring and management in Tanzania’s malaria control program. Document title Organization Reference National Malaria Strategic Plan 2014–2020 NMCP, Tanzania [ 30 ] National Malaria Strategic Plan 2021–2025 NMCP, Tanzania [ 10 ] Integrated Vector Management Guidelines & Standard Operating Procedures MoH, Tanzania [ 32 ] National Guidelines for Integrated Malaria Vector Control (NGIMVC) NMCP, Tanzania [ 34 ] Malaria Surveillance, Monitoring & Evaluation Plan (MSMEP) NMCP, Tanzania [ 35 ] National Strategy for Vector Control 2019–2024 (NSVC) MoH, Tanzania [ 36 ] Tanzania Malaria Indicator Surveys MoH, Tanzania [ 18 , 19 ] National Social and Behavior Change and Advocacy Guide for Malaria Interventions 2021–2025 NMCP, Tanzania [ 40 ] Tanzania (Mainland) Malaria Profile FY 2023 U.S. PMI, Tanzania [ 41 ] Tanzania (Mainland) Malaria Operational Plan FY 2023 U.S. PMI, Tanzania [ 42 ] Global Plan for Insecticide Resistance Management in Malaria Vectors (GPIRM) WHO [ 31 ] Manual for Monitoring Insecticide Resistance in Mosquito Vectors and Selecting Appropriate Interventions WHO [ 37 ] Test procedures for insecticide resistance monitoring in malaria vector mosquitoes (Second edition) WHO [ 43 ] Global Report on Insecticide Resistance in Malaria Vectors WHO [ 38 ] Guidelines for Malaria Vector Control WHO [ 44 ] Framework for a National Plan for Monitoring and Management of Insecticide Resistance in Malaria Vectors WHO [ 39 ] World Malaria Reports 2019–2024 WHO [ 1 , 9 , 45 – 48 ] Note: U.S. PMI denotes the United States President’s Malaria Initiative; WHO, the World Health Organization; MoH, the Ministry of Health and NMCP, National Malaria Control Programme. All documents were publicly available online at the time of access, were downloaded, and are available from the corresponding author upon request if no longer accessible online. Key informant interviews To complement the document review, key informant interviews were conducted with policymakers, representatives of funding agencies, field implementers, and technical experts. The policy-level interviewees included representatives of key government agencies, including the NMCP, the President’s Office-Regional Administration and Local Government (PO-RALG), the National Institute for Medical Research (NIMR), the Tanzania Plant Health and Pesticides Authority (TPHPA), operating under the Ministry of Agriculture (MoA). Others included representatives of non-governmental organizations, namely US President’s Malaria Initiative (PMI), Population Services International (PSI) and the WHO. District and regional level field implementers interviewed included those based in Mwanza, Kigoma, and Tabora regions, where the country was most recently implementing both ITNs and IRS strategies. A total of 24 key informant interviews were completed, either in person or virtually (via Zoom) for participants who were unable to join in-person meetings. Of the 24 participants, 18 were males and 6 were females; and all were between 30–55 years old, and had a tertiary education. The discussions were held primarily in Swahili (Tanzania’s main language) with occasional use of English. Subjects covered included participants’ understanding, perceptions, and opinions on insecticide resistance, insecticide resistance monitoring and management strategies, implementation challenges, and discrepancies between policy and practice. Each interview lasted between one to two hours and was audio-recorded with participants’ permission. Recordings were supplemented with detailed field notes to capture contextual observations. Written informed consent was obtained from all participants before data collection. Data analysis All audio recordings were transcribed word-for-word and thoroughly reviewed to ensure accuracy. To maintain the authenticity and contextual integrity of participants’ responses, transcripts were retained in original language used during the interview (Swahili). The qualitative data were analyzed using thematic content analysis, employing both deductive and inductive approaches to identify pre-defined major themes and emerging themes. NVivo software (version 15)[ 49 ] was used to organize and manage codes, themes, and patterns. The major themes identified included: knowledge and perceptions of insecticide resistance, views on resistance monitoring and surveillance systems, insecticide resistance management strategies, implementation challenges, and discrepancies between policy and actual practice. Results Insights from document review Alignment of national strategies with global IRM frameworks The review of national and international documents revealed that Tanzania has progressively aligned its strategic direction with global frameworks for insecticide resistance monitoring and management (IRM) over the past decade. The NMCP strategic plans (2014–2020 and 2021–2025)[ 10 , 30 ] define the core pillars of Tanzania’s malaria agenda, including integrated vector control; malaria diagnosis, treatment, and preventive therapies; and surveillance, monitoring, and evaluation. These plans are guided by the national vision of a malaria-free society and a mission to ensure equitable access to high-quality, effective, and affordable malaria services through partnerships and community participation. In support of this vision, a suite of policies, frameworks, and technical guidelines have been developed, namely, the Integrated Vector Management Guidelines and Standard Operating Procedures (IVM-SOP) [ 32 ], the National Guidelines for Integrated Malaria Vector Control (NGIMVC) [ 34 ], the Malaria Surveillance, Monitoring and Evaluation Plan (MSMEP) [ 35 ], and the National Strategy for Vector Control 2019–2024 (NSVC) [ 36 ]. Collectively, these documents are consistent with WHO recommendations and key global guidance documents, including the Global Plan for Insecticide Resistance Management in Malaria Vectors (GPIRM) [ 31 ], the Manual for Monitoring Insecticide Resistance in Mosquito Vectors [ 37 ], the Global Report on Insecticide Resistance in Malaria Vectors [ 38 ], and the Framework for a National Plan for Monitoring and Management of Insecticide Resistance in Malaria Vectors [ 39 ]. Integrating of the principles of the global plan for insecticide resistance management (GPIRM) Overall, the reviewed documents indicate that Tanzania has adopted the major pillars of the GPIRM [ 31 ], adapting them to national priorities and operational contexts. In particular, the planning and implementation of IRM strategies, together with systematic surveillance and monitoring of insecticide resistance, are recognized as critical components of the national response. The reviewed frameworks underscore the urgent need for coordinated, proactive, and sustained action to address the increasing threat of resistance, especially in high-burden areas such as the northern, southern, and south-eastern regions of the country as well as the districts bordering Lake Victoria in the north and northwest [ 18 , 19 , 41 ]. Another area of alignment with global recommendations was that Tanzania’s national IRM framework also emphasizes both immediate and long-term interventions such as insecticide rotations, combinations, mosaic spraying, and the use of insecticide mixtures [ 32 ]. More recently, the incorporation of next-generation tools, including piperonyl butoxide (PBO)- ITNs and innovative insecticide formulations for IRS, reflects the country’s commitment to maintaining vector susceptibility and prolonging the efficacy of available insecticides. We observed that Tanzania constantly updates its guidelines to match the WHO pronouncements, and that both the international and national documents constitute the foundation for the planning, execution, and evaluation of integrated vector control interventions. Lastly, the document review found strong alignment with WHO’s standardized guidelines for insecticide resistance monitoring [ 31 ], which advocate the use of validated bioassays, prioritization of key vectors and insecticides for testing, and adaptation of control interventions based on resistance data [ 32 , 35 , 36 ]. Gaps between policy and implementation Despite this strong policy alignment, the review identified persistent gaps between strategic intent and implementation outcomes. The reviews highlight that resource limitations, logistical challenges, and operational inefficiencies continue to hinder full realization of planned activities [ 10 , 30 ]. It was noted that only 22 of the 62 sentinel districts chosen for malaria vector surveillance have been used to monitor insecticide resistance [ 10 ], which makes the national resistance profile less representative. These shortfalls were attributed to delays in ITN distribution, high operational costs of the operations, inadequate financing, and gaps in human and infrastructural capacity, all of which collectively result in suboptimal intervention coverage and limited protection for at-risk populations. Insights from in-depth key informant interviews Knowledge and perception on insecticide resistance Most respondents had a good understanding of insecticide resistance and its impact on malaria control. Some linked it to antimicrobial resistance, and others said that the use of pesticides in farming was a major cause of resistance because the agricultural pesticides are of similar classes to public health insecticides. However, regarding resistance levels and spread in Tanzania, most respondents were unable to provide specific information, citing a lack of accessible statistical data. The quotes below provide further insights: “ Pesticides used in agriculture are also applied in public health, exposing mosquitoes to the same insecticides. This repeated exposure can cause the development of insecticide resistance in vector populations… ” (Male participant, district-level field implementer). “… yes, insecticide resistance is a growing problem. It was once limited to a few areas but has now spread. Although I don’t have enough data, but the problem is serious” (Male participant, regional-level field implementer). Insecticide resistance monitoring and management According to the expert respondents, insecticide resistance monitoring in Tanzania began in 1999, initially focusing on testing the susceptibility of primary malaria vectors to pyrethroids using WHO insecticide susceptibility assays. Over time, the programme has expanded from a few sites to 22 out of 184 sentinel councils nationwide, with a strategic shift to prioritize districts with high malaria prevalence. However, most respondents noted that this coverage is not nationally representative, making it difficult to generalize the findings to the entire country: “…if we had at least one monitoring site in each region, it would improve the representativeness. We can’t reach every area, but covering more councils would give a better national picture. Right now, we talk about representation, but it’s difficult to claim that 22 councils represent the situation in all 184…” (Male participant, technical expert) “...currently, we have about 184 or 185 councils, if I’m not mistaken, but resistance monitoring is conducted in only 22. I believe this coverage is too small to adequately represent the insecticide resistance problem across the entire country” (Female participant, representative of funding agency). Discrepancy in policy and practice Nearly all respondents stated that there were discrepancies between policy and actual practice. They attributed these gaps to factors such as funding and resource constraints, coordination challenges, and shortages of trained personnel. For example, although Tanzania’s current policy recommends deploying multiple interventions using insecticides with different modes of action, such as rotating organophosphates and neonicotinoids for IRS, the stakeholders interviewed here indicated that these stipulated strategies have not been effectively implemented. It was also stated that while insecticide rotations had been the most widely practiced strategy historically, specifically in the districts receiving IRS, this was no longer the case as the practice of IRS had been significantly reduced in Tanzania: …yes, I can say that there is a clear discrepancy between policy and actual practice in the field, largely due to limited resources. The government depends heavily on external funding; as a result, certain interventions, such as IRS, cannot be implemented as prescribed in the policy, particularly after donor support for IRS was withdrawn (Male respondent, policymaker). “Rotation was the most used method, but now it is combination. This was possible due to IRS, but with IRS gone, rotation is no longer used, though it was very effective” (Male participant, district-level field implementer). Concerns related to limited financing as a barrier to effective implementation of insecticide resistance monitoring and management strategies Nearly all respondents identified inadequate financing as a primary barrier to effective implementation. Many noted that although ITNs are intended to be replaced every three years, logistical challenges and funding shortfalls frequently delay distributions, extending replacement cycle: “…our policies are well-designed and clearly articulated; however, the main challenge lies in the lack of funding to implement what is outlined in the policy” (Female respondent, policymaker). “…the main challenge is funding. If NMCP had its own allocated budget from the government, clearly defined with set amounts for specific needs like net procurement, I don’t think there would be such difficulty in implementation” (Male respondent, technical expert). “ You order the insecticide (biolarvicides) to arrive during the dry season when breeding sites are easily identifiable, but the funds are disbursed during the peak of the rainy season ” (Male respondent, district-level field implementer). The respondents also emphasized that, the country is highly depending on donor funds to ensure availability of malaria prevention interventions. They noted that such dependency affects the availability on interventions but also impacts on the selection of appropriate interventions, which they argued is more likely to reflect donor’s and not country preference: “…but most delays are due to reliance on external funding sources, which come with their own bureaucratic procedures that must be followed before funds are released. That’s where the discrepancies arise ” (Male respondent, regional-level field implementer). “ …much of the fight against malaria is donor-funded, if I'm not mistaken, since around 1999. I wonder what our situation will be if they will fully withdraw their support...” (Male participant, technical expert) “One among the challenges for not being able to implement what is indicated within the policy is presence of a lot of priorities at regional and district levels, which inhibit allocation of enough funds for malaria prevention activities” (Female respondent, district-level field implementer). Majority of respondents highlighted the need to mobilize domestic resources to address current funding gaps. They also recommended active engagement of local stakeholders and allocation of revenues from national natural resources, such as mining sectors to strengthen investments in vector control: “ We have abundant natural resources, including mines like Geita Gold Mining and Lakes. Why are we not allocating revenue from these resources to support malaria elimination and resistance management efforts?” (Male participant, regional-level field implementer). “I believe internal funds exist in abundance; it's just a matter of priority. For example, a single wealthy individual and banks like CRDB and NMB can spend a lot of money sponsoring football leagues. I'm not saying it's not important; it is, but the same funders could also be encouraged to support public health initiatives. So why aren’t they being engaged in malaria prevention and elimination efforts ?” (Male participant, technical expert). Concerns related to poor coordination and shortage of trained personnel Respondents identified several additional challenges, including bureaucratic delays in fund disbursement to local councils and poor coordination of roles and activities. In Tanzania, although policies are formulated at the national level, implementation occurs at the council level, where guidelines are often distributed but insufficiently disseminated, leading to limited ownership among implementers. Some participants noted overlapping or unclear responsibilities between the Ministry of Health (MoH) and the President’s Office-Regional Administration and Local Government (PO-RALG): the MoH develops policies and strategic plans, while PO-RALG oversees implementation. This structural arrangement has resulted in sub-optimal engagement of district-level operators, fund misallocation, staffing challenges, and a top-down approach that limits input from local implementers. This has also contributed to delays in execution of insecticide resistance management activities. “ The main challenge causing discrepancies is the communication gap between national policymakers and council-level implementers. Plans are made at the top, but implementation happens at the grassroots...” (Male respondent, regional-level field implementer). “…I would say the guidelines are distributed but not effectively disseminated, which cause some local implementers to lose their sense of ownership…” (Female respondent, district-level field implementer). “…for example, I assessed the larvicide needs in my council, including coverage and costs, totaling nearly 22 million TZS. However, I was later informed during a regional meeting that only 4.5 million TZS was available. I was left wondering how to proceed...” (Male respondent, district-level field implementer). Another concern was the lack of formal recognition for personnel trained at the Vector Control Training Centre (VCTC) in Tanga, whose salaries remain at volunteer level despite completing two to three years of specialized training. Accordingly, respondents stressed that, alongside regular training and proper coordination, which are essential for effective insecticide resistance management, policymakers should actively disseminate guidelines and provide context-specific training to local implementers: “...regular trainings are essential and I suggest that those staff who attended the training at our college in Tanga (Vector Control Training Centre), should be considered for appropriate salary scale categorization to enhance their motivation, …every district should have a dedicated vector control specialist, such as an entomologist, to strengthen vector control efforts at the district level, unlike the current situation” (Male participant, district-level field implementer). Inadequate community malaria education and engagement Respondents identified insufficient community-based malaria education as a key factor widening the policy-practice gap. Participants stressed that malaria elimination demands robust community engagement and culturally tailored behavior change communication. Educated communities are more apt to sustain preventive practices, such as using insecticide-treated nets and managing mosquito breeding sites. Additionally, involving religious and political leaders as advocates was considered vital for community mobilization, perception shifting, and widespread adoption of malaria prevention and resistance management strategies: “…. to ensure successful elimination, we should also invest in behavior change design and campaigns aimed at altering community perceptions on malaria and interventions, tailored to the specific characteristics of each region..” (Male participant, regional-level field implementer). “Once a person is educated, even the interventions you plan to introduce become much easier to implement and use. Therefore, in the fight against malaria, we must invest significantly in educating the community. I believe that if the community is fully educated, the malaria problem can be reduced to more than 50%” (Male participant, technical expert). Perceptions on the current malaria control targets When asked about the adequacy of current strategies and tools to address insecticide resistance and achieve malaria elimination by 2030, most respondents expressed skepticism. The discontinuation of IRS and limited support for biolarviciding were viewed as major barriers to sustaining progress. Participants agreed that achieving elimination targets will require reduced dependence on external funding and increased domestic resource mobilization. They emphasized the need to elevate malaria control and IRM to national priorities, comparable to the country’s response to other major diseases such as HIV/AIDS. Strengthening intersectoral collaboration, particularly among the Ministry of Health (MoH), Ministry of Agriculture (MoA), and the Ministry of Infrastructure, was also identified as essential to advancing national malaria elimination efforts “… eliminating malaria by 2030 is like a dream; let’s be honest. It will only be possible with blanket larviciding; otherwise, it remains just a dream. Even regions with less than 1% malaria prevalence are simply benefiting from colder climates that are unfavorable for mosquito breeding” (Male participant, regional-level field implementer). “ Due to the withdrawal of the IRS and the lack of donor support for biolarviciding, achieving the goal of reducing transmission by 90% and mitigating resistance will be highly challenging ” (Female participant, technical expert). Discussion This study examined the alignment between national policies and on-the-ground implementation of insecticide resistance management strategies in Tanzania’s malaria control ecosystem. It critically evaluated national insecticide resistance monitoring and management (IRM) strategies and identified key barriers and policy-practice gaps. Although the NMCP has established comprehensive frameworks consistent with WHO recommendations, substantial implementation challenges remain. These challenges stem from limited resources, constrained surveillance coverage, reliance on external funding, and weak coordination across administrative levels. While these challenges are not unique to Tanzania, similar obstacles are widely documented across malaria-endemic countries in sub-Saharan Africa, where the transition from policy formulation to effective operationalization remains a major bottleneck in resistance management and vector control [ 24 , 27 , 50 – 53 ]. The findings from this study highlight the urgent need for stronger domestic financing, improved multisectoral collaboration, and sustained community engagement to ensure that national policy commitments translate into measurable progress toward malaria elimination. Persistent funding and resource constraints, coupled with heavy donor dependence, pose major challenges to effective IRM and malaria elimination. Over the past decade, more than two-thirds of malaria control investments in endemic countries have relied on external funding. In Tanzania, approximately 90% of malaria financing is provided by the Global Fund (GF) and the President’s Malaria Initiative (PMI), contributing an estimated USD 265 million during 2021–2023 [ 10 ]. However, a funding gap exceeding USD 200 million remains for the 2021–2025 strategic plan [ 10 ]. While these partnerships have enhanced program efficiency and targeted resource allocation [ 4 , 54 – 56 ], delays linked to procurement and tendering processes [ 25 , 57 ] underscore the vulnerabilities of donor dependence. Consistent with prior studies highlighting the pivotal role of internal financing in malaria control [ 24 , 58 – 60 ], this study underscores the critical importance of strengthening domestic resource mobilization to ensure sustainable malaria control and elimination, particularly amid recent donor funding cuts from agencies such as USAID [ 10 , 58 , 61 ]. Although Tanzania’s economy may not yet match international contributions [ 62 ], increasing domestic financing could strengthen IRM implementation by expanding surveillance and monitoring coverage and enabling the effective deployment of previously abandoned, donor-unsupported strategies such as IRS and larviciding [ 31 , 38 ]. Beyond funding, enhanced community engagement and education, improved coordination, adequate human resources, and effective decentralization of health services are critical for successful malaria control interventions [ 60 , 63 – 66 ]. Our study underscores that engaging influential community figures, such as religious leaders, local chiefs, and politicians, can strengthen IRM implementation and advance malaria elimination goals. Consistent with previous evidence [ 65 , 67 – 70 ], community acceptability and participation are pivotal to the success of interventions, as they cultivate local ownership and sustainability. Ensuring that communities are meaningfully engaged throughout planning, implementation, and dissemination phases allows their priorities and concerns to be addressed, which enhances acceptance and uptake [ 71 ]. This is particularly important given ongoing efforts by the NMCP to expand knowledge and awareness of malaria and its interventions within Tanzanian communities [ 40 ]. Furthermore, robust intersectoral collaboration, strengthened institutional coordination, and a well-trained health workforce equipped with continuous professional development and policy guidance are equally vital for sustaining effective IRM implementation [ 27 , 72 – 74 ]. This study aimed to provide additional insights to support ongoing IRM strategies and was not intended to alter NMCP or partner efforts in malaria control. It acknowledges the success of national policies emphasizing routine resistance monitoring, evidence-based vector control, and insecticide rotation aligned with global IRM frameworks [ 32 , 34 , 35 ]. The national monitoring system, despite covering few sites, has produced high-quality resistance data, demonstrating the NMCP’s strong commitment to surveillance [ 10 , 32 , 35 ]. Similarly, insecticide management strategies, including rotating non-pyrethroid insecticides for IRS and transitioning to next-generation ITNs, have successfully restored mosquito susceptibility in several regions [ 10 , 30 ]. However, implementation has been inconsistent, particularly following IRS withdrawal and recent funding reductions [ 75 – 78 ]. This study highlights the urgent need to address implementation barriers to ensure effective insecticide resistance management and malaria control. Consistent with existing evidence on the role of non-pyrethroid interventions in managing resistance [ 79 – 84 ], the findings also underscore the importance of reintroducing non-pyrethroid IRS where appropriate and fully implementing complementary measures such as larviciding. We propose recommendations (Table 2) to strengthen IRM implementation and accelerate malaria elimination in Tanzania. Table 2: Summary of recommendations to address the challenges hindering the effective IRM and malaria elimination efforts in Tanzania Challenge Recommendation(s) Funding and resource constraints, and donor dependence Increase domestic funding and resource mobilization through public-private partnerships, improved taxation, health levies, innovative tools such as diaspora bonds, and efficient use of natural resource revenues Enhance governance, transparency, and accountability, while reducing corruption Poor coordination and shortage of trained personnel Establish a well-defined coordination unity for IRM with a clear mandate and dedicated budget Disseminate guidelines and provide context-specific training to local implementers Revise salary scales for VCTC-trained vector control staff at regional and district levels to improve motivation Inadequate community malaria education and engagement Scale up community engagement and culturally tailored behavior change campaigns involving e ntire community, religious leaders, local chiefs and politicians Integrate malaria education into school curricula and existing media platforms, including television and radio Despite the novelty of this study, its findings should not be generalized to other health issues or sectors, as it is limited to examining challenges and gaps in implementing vector control strategies in Tanzania within the context of insecticide-resistance monitoring and management. The analysis reflects policies and implementation practices at a specific point in time and may not capture recent policy changes or ongoing initiatives. Although the number of in-depth interviews was relatively small and drawn from a few regions, efforts were made to engage key stakeholders, including policymakers, funders, technical experts, and implementers at both regional and district levels, who are representative of the target group. In addition, while the document review was constrained by the availability of publicly accessible policy materials, the inclusion of relevant documents from the NMCP and WHO strengthened the study’s contextual validity and relevance. Conclusions This study provides compelling evidence that, although Tanzania’s malaria control frameworks align with global best practices, their implementation remains constrained by persistent operational and systemic challenges. These include funding shortfalls, donor reliance, limited capacity, weak coordination, low community engagement, poor intersectoral collaboration, and sociocultural barriers. These challenges threaten progress toward malaria elimination by 2030. Addressing these policy-practice gaps in insecticide resistance management will require sustained financing, stronger coordination, expanded surveillance, and enhanced community and intersectoral participation. Prioritizing these actions is critical not only for effective resistance management but also for realizing the national goal of a malaria-free Tanzania. Declarations Acknowledgements The authors would like to thank the members of NMCP, NIMR, IHI, PO-RALG, TPHPA, PSI, PMI, WHO and implementers from Mwanza, Kigoma and Tabora regions for their valuable participation in this study. We are also grateful for the support provided by the OMC team at IHI and by Heka Mapunda of TTCIH. Author contributions HEG, MMM, YPM, HSN, PS and FOO designed and conceptualized the study. HEG, IRM, IHN, GGS, RMN, SSM, RPN and CDM involved in data collection and analysis. HEG and IRM wrote initial and subsequent drafts of the manuscript. MMM, YPM, IRM, HSN, PS and FOO supervised the study and reviewed the study protocols and all drafts of the manuscript. All authors revised the final manuscript and approved the submission. Ethical approval and consent to participate Ethical approval for this study was obtained from the Institutional Review Board (IRB) of the Ifakara Health Institute (IHI/IRB/EXT/No: 44-2024) and from the Medical Research Coordination Committee of the National Institute for Medical Research (NIMR), Tanzania (NIMR/HQ/R.8c/Vol.I/2937). Consent for publication All authors agreed to publish this manuscript. Funding This work was supported by the Gates Foundation through the African Consortium in Modelling for Effective Vector Control (ACoMVeC) project (grant no. INV-047049). The funder had no role in the study design, data collection, analysis, manuscript preparation or publication decision. Competing interest Charles D. Mwalimu and Rosemary P. Nshama are affiliated with the National Malaria Control Programme (NMCP). The authors declare no other conflicts of interest. Data availability Data are available from the corresponding author(s) upon reasonable request. Author details 1 Nelson Mandela African Institution of Science and Technology (NM-AIST), P.O. Box 447, Arusha, Tanzania. 2 Environmental Health and Ecological Science Department, Ifakara Health Institute, P.O. Box 53, Ifakara, Tanzania. 3 Department of Mathematics and Statistics, University of Dodoma, P.O. Box 338, Dodoma, Tanzania. 4 Institute for Diseases Modeling, Gates Foundation, Global Health Division, Seattle, Washington, United States of America. 5 School of Biodiversity, One Health and Veterinary Medicine, G12 8QQ, University of Glasgow, Glasgow, UK & 6 National Malaria Control Programme (NMCP), Dodoma, Tanzania. References WHO. World malaria report 2024: Addressing inequity in the global malaria response. Geneva: World Health Organization; 2024. WHO. WHO guidelines for malaria. Geneva: World Health Organization; 2023. WHO. Seventeenth Meeting of the WHO Vector Control Advisory Group Meeting Report. Geneva: World Health Organization; 2023. Okumu F, Gyapong M, Casamitjana N, Castro MC, Itoe MA, Okonofua F, et al. What Africa can do to accelerate and sustain progress against malaria. PLOS Glob Public Health. 2022;2:e0000262. WHO. WHO recommends R21/Matrix-M vaccine for malaria prevention in updated advice on immunization. Geneva: World Health Organization; 2023. Bhatt S, Weiss DJ, Cameron E, Bisanzio D, Mappin B, Dalrymple U, et al. The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015. Nature. 2015;526:207–11. Lindsay SW, Thomas MB, Kleinschmidt I. Threats to the effectiveness of insecticide-treated bednets for malaria control: thinking beyond insecticide resistance. Lancet Glob Health. 2021;9:e1325–31. Landier J, Parker DM, Thu AM, Carrara VI, Lwin KM, Bonnington CA, et al. The role of early detection and treatment in malaria elimination. Malar J. 2016;15:363. WHO. World malaria report 2023: Tracking progress and gaps in the global response to malaria. Geneva:World Health Organization; 2023. National Malaria Control Programme. National Malaria Strategic plan 2021–2025 Transitioning to Malaria Elimination in Phases. Tanzania. 2020. https://www.nmcp.go.tz/publication . Accessed 13 Apr 2024. Clyde DF. Malaria control in Tanganyika under the German Administration. I. E. East Afr Med J. 1961;38:27–42. Turshen M. The impact of colonialism on health and health services in Tanzania. Int J Health Serv. 1977;7:7–35. Yhdego M, Majura P. Malaria control in Tanzania. Environ Int Pergamon. 1988;14:479–83. Kulkarni MA, Malima R, Mosha FW, Msangi S, Mrema E, Kabula B, et al. Efficacy of pyrethroid-treated nets against malaria vectors and nuisance-biting mosquitoes in Tanzania in areas with long-term insecticide-treated net use. Trop Med Int Health. 2007;12:1061–73. WHO. RBM-progress and impact series: country reports: focus on mainland Tanzania. Geneva: World Health Organization; 2012. Caldas De Castro M, Yamagata Y, Mtasiwa D, Tanner M, Utzinger J, Keiser J, et al. Integrated urban malaria control: a case study in Dar es salaam, Tanzania. Am J Trop Med Hyg. 2004;71:103–17. Tungu P, Kabula B, Nkya T, Machafuko P, Sambu E, Batengana B, et al. Trends of insecticide resistance monitoring in mainland Tanzania, 2004–2020. Malar J. 2023;22:1–16. Ministry of Health Community Development Gender Elderly and Children [Tanzania Mainland]. Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS) Office of the Chief Government Statistician, and ICF. Tanzania Malaria Indicator Survey 2017 . Dar es Salaam, Tanzania, and Rockville, Maryland, USA: MoHCDGEC, MoH, NBS, OCGS, and ICF; 2017. Ministry of Health (MoH). [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2022 Final Report . Dodoma, Tanzania, and Rockville, Maryland, USA: MoH, NBS, OCGS, and ICF; 2022. Kabula B, Mlacha YP, Serbantez N, Nhiga SL, Mkude S, Kiware S, et al. Pyrethroid-resistant malaria vector Anopheles gambiae restored susceptibility after pre-exposure to piperonyl-butoxide: results from country-wide insecticide resistance monitoring in Tanzania, 2023. Malar J. 2024;23:1–16. Mwalimu CD, Kiware S, Nshama R, Derua Y, Machafuko P, Gitanya P et al. Dynamics of malaria vector composition and Plasmodium falciparum infection in mainland Tanzania: 2017–2021 data from the national malaria vector entomological surveillance. Malar J. 2024;23. Sokhna C, Ndiath MO, Rogier C. The changes in mosquito vector behaviour and the emerging resistance to insecticides will challenge the decline of malaria. Clin Microbiol Infect. 2013;19:902–7. Odero JO, Nambunga IH, Masalu JP, Mkandawile G, Bwanary H, Hape EE, et al. Genetic markers associated with the widespread insecticide resistance in malaria vector Anopheles funestus populations across Tanzania. Parasit Vectors. 2024;17:230. Mnzava AP, Knox TB, Temu EA, Trett A, Fornadel C, Hemingway J, et al. Implementation of the global plan for insecticide resistance management in malaria vectors: Progress, challenges and the way forward. Malar J. 2015;14:1–9. Njau RJA, De Savigny D, Gilson L, Mwageni E, Mosha FW. Implementation of an insecticide-treated net subsidy scheme under a public-private partnership for malaria control in Tanzania - Challenges in implementation. Malar J. 2009;8:1–27. Mlozi Malongo R, Susan M, Tabitha B, Veneranda S, Elizabeth M, Benjamin et al. Challenges and opportunities for implementing an intersectoral approach in malaria control in Tanzania. Tanzan J Health Res. 2015; 17. Mwendera CA, De Jager C, Longwe H, Kumwenda S, Hongoro C, Phiri K, et al. Challenges to the implementation of malaria policies in Malawi. BMC Health Serv Res. 2019;19:1–9. Cohen JM, Okumu F, Moonen B. The fight against malaria: Diminishing gains and growing challenges. Sci Transl Med. 2022;14:eabn3256. Alonso PL, Tanner M. Public health challenges and prospects for malaria control and elimination. Nat Med. 2013;19:150–5. National Malaria Control Programme. National Malaria Strategic Plan 2014–2020, Abridged Version. Tanzania. 2014. https://www.nmcp.go.tz/publication . Accessed 13 Apr 2024. WHO. Global Plan for Insecticide Resistance Management in Malaria Vectors: executive summary. Geneva: World Health Organization; 2012. Ministry of Health. Integrated Vector Management Guidelines and Standard Operating Procedures. Tanzania. 2023. https://www.nmcp.go.tz/publication . Accessed 10 Feb 2024. Kailembo D, Gavana T, Kasagama E, Bernard J, Molteni F, Kisoka N, et al. Large-scale intermittent larviciding intervention and associations with key malaria epidemiological parameters in Tanga Region, Tanzania. Malar J. 2025;24:350. National Malaria Control Programme. National Guidelines for Integrated Malaria Vector Control. Tanzania. 2016. https://www.nmcp.go.tz/publication . Accessed 12 Mar 2024. National Malaria Control Programme. Malaria Surveillance, Monitoring and Evaluation Plan, 2021–2025. Tanzania. 2022. https://www.nmcp.go.tz/publication . Accessed 14 Apr 2024. Ministry of Health. National Strategy for Vector Control 2019–2024. Tanzania. 2019. https://www.moh.go.tz/report . Accessed 10 Apr 2024. WHO. Manual for monitoring insecticide resistance in mosquito vectors and selecting appropriate interventions. Geneva: World Health Organization; 2022. WHO. Global report on insecticide resistance in malaria vectors: 2010–2016. Geneva: World Health Organization; 2018. WHO. Framework for a national plan for monitoring and management of insecticide resistance in malaria vectors. Geneva: World Health Organization; 2016. National Malaria Control Programme. National Social and Behavour Change & Advocacy Guide for Malaria Interventions 2021–2025. Tanzania; 2020. . Accessed 15 Apr 2024. U.S. President’s Malaria Initiative. Tanzania (Mainland) Malaria Profile FY 2023. 2023. https://mesamalaria.org/wp-content/uploads/2025/04/TANZANIA-MAINLAND-Malaria-Profile-PMI-FY-2024.pdf . Accessed 13 Mar 2024. U.S. President’s Malaria Initiative. Tanzania (Mainland) Malaria Operational Plan FY 2023. https://reliefweb.int/report/united-republic-tanzania/presidents-malaria-initiative-tanzania-malaria-operational-plan-fy-2023 . Accessed 11 Feb 2024. WHO. Test procedures for insecticide resistance monitoring in malaria vector mosquitoes (Second edition). Geneva: World Health Organization; 2018. WHO. Guidelines for Malaria Vector Control. Geneva: World Health Organization; 2019. WHO. World malaria report 2022: Tracking progress and gaps in the global response to malaria. Geneva: World Health Organization; 2022. WHO. World malaria report 2021: Tracking progress against malaria. Geneva: World Health Organization; 2021. WHO. World Malaria Report 2020: 20 years of global progress & challenges. Geneva: World Health Organization; 2020. WHO. World malaria report 2019. Geneva: World Health Organization; 2019. Allsop DB, Chelladurai JM, Kimball ER, Marks LD, Hendricks JJ. Qualitative Methods with Nvivo Software: A Practical Guide for Analyzing Qualitative Data. Psych. 2022;4:142–59. Win Han Oo, Nguyen XT, Ngo TVA, Ngo DT, Win Htike, Aye Tun N, et al. Performance and feasibility of reactive surveillance and response strategies for malaria elimination in Vietnam: a mixed-methods study. Malar J. 2023;22:1–13. Tabue RN, Gbalegba CGN, Mwalimu CD, Tungu PK, Fodjo BK, Elanga-Ndille E, et al. Managing insecticide resistance in malaria vectors in Africa: case studies from Cameroon, Côte d’Ivoire and Tanzania. Malar J. 2025;24:1–17. WHO. Implementation of Indoor Residual Spraying of Insecticides for Malaria Control in the WHO African Region Report. Geneva:World Health Organization; 2007. Suuron VM, Mwanri L, Tsourtos G, Owusu-Addo E. An exploratory study of the acceptability of indoor residual spraying for malaria control in upper western Ghana. BMC Public Health. 2020;20:465. Harbour C, Hempstone H, Brasington A, Agha S. How donors can collaborate to improve reach, quality, and impact in social and behavior change for health. Glob Health Sci Pract. 2021;9:246–53. Mishra V. The Role and Importance of External Donor-Funded DFI’s. In: Kararach G, MEP MV, editors. The Palgrave Handbook of Development Finance. Cham: Palgrave Macmillan; 2025. pp. 285–305. Parkhurst J, Ghilardi L, Webster J, Snow RW, Lynch CA. Competing interests, clashing ideas and institutionalizing influence: insights into the political economy of malaria control from seven African countries. Health Policy Plan. 2021;36:35–44. Kollipara A, Moonasar D, Balawanth R, Silal SP, Yuen A, Fox K, et al. Mobilizing resources with an investment case to mitigate cross-border malaria transmission and achieve malaria elimination in South Africa. Glob Health Action. 2023;16:2205700. Okumu F, Odero JO, Charlwood JD, Knols BGJ, Monroe A. Safeguarding malaria control gains in Africa through ‘species sanitation’ and structural resilience. Trends Parasitol. 2025;41:720–33. Africa CDC. Africa’s Health Financing in a New Era: Concept Paper. Addis Ababa: Centers for Disease Control and Prevention; 2025. Oladipo HJ, Tajudeen YA, Oladunjoye IO, Yusuff SI, Yusuf RO, Oluwaseyi EM, et al. Increasing challenges of malaria control in sub-Saharan Africa: Priorities for public health research and policymakers. Ann Med Surg (Lond). 2022;81:104366. Matindo AY, Meshi EB, Kapologwe NA, Kengia JT, Kajange S, Chaki P, et al. Biolarviciding implementation in southern Tanzania: Scalability opportunities and challenges. PLoS ONE. 2022;17:e0273490. Thomas Mori A, Christopher Bulula N, Magodi R, Mwengee W. Domestic funding opportunities for Tanzania as five new Middle-Income countries brace for reduced Gavi support for immunization. Vaccine. 2022;40:3278–85. Moshi IR, Ngowo H, Dillip A, Msellemu D, Madumla EP, Okumu FO, et al. Community perceptions on outdoor malaria transmission in Kilombero Valley, Southern Tanzania. Malar J. 2017;16:1–8. Mswati IK. An Africa free of malaria. Lancet. 2019;394:988–9. Mapua SA, Finda MF, Nambunga IH, Msugupakulya BJ, Ukio K, Chaki PP, et al. Addressing key gaps in implementation of mosquito larviciding to accelerate malaria vector control in southern Tanzania: results of a stakeholder engagement process in local district councils. Malar J. 2021;20:1–14. Oxman AD, Lewin S, Lavis JN, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 15: Engaging the public in evidence-informed policymaking. Health Res Policy Syst. 2010;10:520–6. Finda MF, Moshi IR, Monroe A, Limwagu AJ, Nyoni AP, Swai JK et al. Linking human behaviours and malaria vector biting risk in south-eastern Tanzania. PLoS ONE. 2019;14. Baltzell K, Harvard K, Hanley M, Gosling R, Chen I. What is community engagement and how can it drive malaria elimination? Case studies and stakeholder interviews. Malar J. 2019;18:1–11. Bardosh K, Desir L, Jean L, Yoss S, Poovey B, Nute A, et al. Evaluating a community engagement model for malaria elimination in Haiti: lessons from the community health council project (2019–2021). Malar J. 2023;22:1–13. Okumu F, Moore SJ, Selvaraj P, Yafin AH, Juma EO, Shirima GSG, et al. Elevating larval source management as a key strategy for controlling malaria and other vector-borne diseases in Africa. Parasit Vectors. 2025;18:1–19. Bartumeus F, Costa GB, Eritja R, Kelly AH, Finda M, Lezaun J, et al. Sustainable innovation in vector control requires strong partnerships with communities. PLoS Negl Trop Dis Public Libr Sci. 2019;13:e0007204. Obeagu EI, Obeagu GU. Emerging public health strategies in malaria control: innovations and implications. Ann Med Surg (Lond). 2024;86:6576–84. Chandler CIR, Jones C, Boniface G, Juma K, Reyburn H, Whitty CJM. Guidelines and mindlines: Why do clinical staff over-diagnose malaria in Tanzania? A qualitative study. Malar J. 2008;7:1–13. Rulisa A, van Kempen L, Hakizimana E, Koenraadt CJM. Local resource mobilization for malaria vector control among Rwandan rice farmers: a pilot study into the role of community ownership. J Health Popul Nutr. 2023;42:1–19. Mwalimu C, Lazaro S, Kisinza W, Magesa S, Kiware S. The impact of Indoor Residual Spraying (IRS) withdrawal in the Lake Zone Regions in Mainland Tanzania. Should Tanzania withdrawal its IRS program? 2023; https://doi.org/10.21203/rs.3.rs-2888818/v1 Sohel MdS. How USAID Budget Cuts Threaten Global Health System. DIU J Allied Health Sci. 2024;11:14–6. Mbah Ruth H, Caden M, Drusilla N, Alyssa, Russell Jordan. The Impact of USAID Budget Cuts on Global Development Initiatives: A Review of Challenges, Responses, and Implications. Adv Soc Sci Res J. 2025; 12. Hussein S, Samet JM. Measuring population health impact of the Trump administration’s withdrawal from WHO and cuts to USAID: time to start counting. Popul Health Metr. 2025;23:13. Bisanzio D, Ally M, Ali AS, Kitojo C, Serbantez N, Kisinza WN, et al. Modelling insecticide resistance of malaria vector populations in Tanzania. Am J Trop Med Hyg. 2022;107:308–14. Aïkpon R, Agossa F, Ossè R, Oussou O, Aïzoun N, Oké-Agbo F, et al. Bendiocarb resistance in Anopheles gambiae s.l. populations from Atacora department in Benin, West Africa: a threat for malaria vector control. Parasit Vectors. 2013;6:192. Dandi-Labou J, Kengne-Ouafo JA, Mugenzi L, Tchouakui M, Wondji M, Wondji CS. Susceptibility profile of Anopheles and target site resistance mechanism against organophosphates in Cameroon. PLoS ONE. 2025;20:e0321825. Zoungbédji DM, Padonou GG, Konkon AK, Hougbe S, Sagbohan H, Kpanou C, et al. Assessing the susceptibility and efficacy of traditional neurotoxic (pyrethroid) and new-generation insecticides (chlorfenapyr, clothianidin, and pyriproxyfen), on wild pyrethroid-resistant populations of Anopheles gambiae from southern Benin. Malar J. 2023;22:245. Gervas HE, Mayengo MM, Mlacha YP, Ngowo HS, Okumu FO, Selvaraj P. Modelling the impact of different intervention packages for malaria control under varying intensities of pyrethroid resistance. Malar J Malar J. 2025;24:411. Pinda PG, Eichenberger C, Ngowo HS, Msaky DS, Abbasi S, Kihonda J, et al. Comparative assessment of insecticide resistance phenotypes in two major malaria vectors, Anopheles funestus and Anopheles arabiensis in south-eastern Tanzania. Malar J. 2020;19:1–11. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 15 Feb, 2026 Reviewers invited by journal 27 Jan, 2026 Editor assigned by journal 28 Dec, 2025 Submission checks completed at journal 24 Dec, 2025 First submitted to journal 24 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8439202","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581392091,"identity":"5366328c-c2ef-4023-bb98-73b1014e8904","order_by":0,"name":"Hamenyimana E. Gervas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYBACAygtxybB2ECaFmOYFgmitSQ2QNUS1mLOv/jYZ56auvQ+6eYGho97GOrkCbnPcsaz5Nk8xw7ntskcbGCc8YyBsJcMbpwxZpzBdiC3TSKxgZnnAIMEMyGHGdw4/5lxxr+6dDaYFjaCWs73MDN8bGNOgGvhIWwLmzHDx77DhiCHHZxxQEJyBmFbDj9mSPhWJy8/I/3hgw8HbPgJhhiDRAKCfYCYaGFg4D9AhKJRMApGwSgY2QAAVq07ja+UB/YAAAAASUVORK5CYII=","orcid":"","institution":"Nelson Mandela African Institution of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Hamenyimana","middleName":"E.","lastName":"Gervas","suffix":""},{"id":581392092,"identity":"7d88cd72-bdb2-4225-bcdb-1e0d2257077b","order_by":1,"name":"Irene R. Moshi","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Irene","middleName":"R.","lastName":"Moshi","suffix":""},{"id":581392093,"identity":"2025c5e2-a3ff-4a8b-bc7d-177ac7a5f634","order_by":2,"name":"GloriaSalome G. Shirima","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"GloriaSalome","middleName":"G.","lastName":"Shirima","suffix":""},{"id":581392094,"identity":"3246629e-457b-4b52-a37c-dc33b4c85d51","order_by":3,"name":"Ismail H. Nambunga","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Ismail","middleName":"H.","lastName":"Nambunga","suffix":""},{"id":581392095,"identity":"09aa5aaf-b722-4f88-9996-e76754773f9a","order_by":4,"name":"Rukiyah M. Njalambaha","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Rukiyah","middleName":"M.","lastName":"Njalambaha","suffix":""},{"id":581392096,"identity":"920931c7-0962-42c8-ada6-d7c2356ee8b4","order_by":5,"name":"Sheikha S. Mohamed","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Sheikha","middleName":"S.","lastName":"Mohamed","suffix":""},{"id":581392097,"identity":"d2bd30c0-1906-4b0b-a5d1-ab25b21282ff","order_by":6,"name":"Rosemary P. Nshama","email":"","orcid":"","institution":"Ministry of Health and Social Welfare","correspondingAuthor":false,"prefix":"","firstName":"Rosemary","middleName":"P.","lastName":"Nshama","suffix":""},{"id":581392098,"identity":"43f713a4-488d-4f95-adcc-d8f7ce94982f","order_by":7,"name":"Charles D. Mwalimu","email":"","orcid":"","institution":"Ministry of Health and Social Welfare","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"D.","lastName":"Mwalimu","suffix":""},{"id":581392099,"identity":"e9943a09-7803-4117-a018-b3f1a828d9d9","order_by":8,"name":"Maranya M. Mayengo","email":"","orcid":"","institution":"Nelson Mandela African Institution of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Maranya","middleName":"M.","lastName":"Mayengo","suffix":""},{"id":581392100,"identity":"0a4af496-4ca8-4884-8cc6-a4cd25d2d1a5","order_by":9,"name":"Yeromin P. Mlacha","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Yeromin","middleName":"P.","lastName":"Mlacha","suffix":""},{"id":581392101,"identity":"ebb51e17-a9d1-4937-b92d-0e069b77d299","order_by":10,"name":"Prashanth Selvaraj","email":"","orcid":"","institution":"Bill \u0026 Melinda Gates Foundation","correspondingAuthor":false,"prefix":"","firstName":"Prashanth","middleName":"","lastName":"Selvaraj","suffix":""},{"id":581392102,"identity":"edab84aa-60ae-4f94-a47c-c4335f5e7b4a","order_by":11,"name":"Fredros O. Okumu","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Fredros","middleName":"O.","lastName":"Okumu","suffix":""},{"id":581392103,"identity":"e7980d34-a5c4-407e-bf1b-10a8ac1f5273","order_by":12,"name":"Halfan S. Ngowo","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Halfan","middleName":"S.","lastName":"Ngowo","suffix":""}],"badges":[],"createdAt":"2025-12-24 05:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8439202/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8439202/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101751430,"identity":"3dee247f-2b4c-4b05-9fe6-24c2ea0b7473","added_by":"auto","created_at":"2026-02-03 10:20:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1087398,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8439202/v1/6a09484e-a346-4a0d-91d7-3953932123dd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Policy-practice gaps and barriers to the effective management of insecticide resistance in Tanzania","fulltext":[{"header":"Background","content":"\u003cp\u003eAlthough malaria is preventable and treatable, it remains a major health challenge in Africa, disproportionately affecting the poor and marginalized populations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite substantial progress driven by interventions such as insecticide-treated nets (ITNs), indoor residual spraying (IRS), effective diagnosis and treatment, preventive therapies, and more recently, vaccines [\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], this progress has slowed, and in some areas stalled or even reversed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This stagnation is driven by multiple factors, including rising commodity costs amid dwindling resources, increasing insecticide and drug resistance, inadequate adherence of the affected population to the interventions, and suboptimal intervention coverage, underscoring a widening gap between current progress and the global malaria control targets [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Tanzania, malaria vector control has historically been predominated by insecticide-based approaches complemented with environmental sanitation [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For decades, these efforts were organized through local health systems, until the National Malaria Control Programme (NMCP), established in 1990 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], began reinforcing nationally coordinated and regional initiatives [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. From the early 1990s, ITN delivery strategies were piloted in Bagamoyo and Kilombero, leading to nationwide ITN scale-up starting in the late 1990s [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. IRS was relaunched in 2007, initially covering two districts and later expanding to 18 councils in three regions of the north-west and Lake zone, using pyrethroids at first, followed by bendiocarb, and from 2014 onward, organophosphates [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, in 2020, IRS was done in only six districts with the highest malaria burden regions in the same zone [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOver 60\u0026nbsp;million ITNs were distributed between 2009 and 2020, with continued large-scale distribution through antenatal care and immunization programs, schools, and mass campaigns [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Because of these efforts, and the expanded case management [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], malaria prevalence among children fell from 14% in 2016 to 7.5% in 2017 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], but unexpectedly reversed to 8.1% in 2022, with the highest rates exceeding 15% in the Lake, Western and Southern Zones [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This coincided with the expansion of pyrethroid resistance, with the proportion of sentinel sites showing evidence of resistance increasing from 0% in 2004 to over 80% by 2020 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This widespread pyrethroid resistance among \u003cem\u003eAnopheles\u003c/em\u003e mosquitoes poses a major challenge to the effectiveness and long-term sustainability of pyrethroid-based vector control programs in Tanzania, threatening progress toward malaria elimination [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTanzanian public health authorities have made several efforts to address these insecticide resistance challenges, aligning with global and regional practices [\u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The NMCP strategic plans and guidelines have consistently included actions to manage insecticide resistance, informed by both local evidence and international recommendations [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These frameworks serve as implementation roadmaps, emphasizing strategies such as insecticide rotation for IRS, combined use of ITNs and IRS with different active ingredients, the application of insecticide mixtures and mosaics to enhance vector control [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and more recently the deployment of new generation ITNs that include either insecticide synergists or multiple active ingredients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and the scale-up of larval source management (LSM) across the country [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite well-structured plans, implementing interventions to achieve targeted goals has historically been challenging [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], with success requiring context-specific strategies and solutions unique to Tanzania. For instance, delays in ITN distribution reported in strategic plans [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] are not simply due to negligence or a lack of commitment; rather, they underscore the inherent difficulty in translating strategic goals into effective implementation. Critical questions remain about the discrepancies between insecticide resistance monitoring and management (IRM) policies and their on-the-ground implementation, the barriers hindering effective IRM strategies, and the resulting constraints on malaria elimination efforts. Consequently, Tanzania's prospects for achieving nationwide malaria elimination in the near future remain uncertain.\u003c/p\u003e \u003cp\u003eThis current study aimed to critically assess the national strategies for insecticide resistance monitoring and management in Tanzania, with the objective of identifying key barriers and misalignments between policy and actual practice. To achieve this, we used a combination of an in-depth review of key technical documents underpinning IRM practices in Tanzania and internationally, alongside an analysis of the opinions and perspectives of key stakeholders in vector control activities in the country.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eDocument review\u003c/strong\u003e \u003cp\u003e This study was conducted between February and November 2024 and commenced with a comprehensive document review aimed at assessing national and international policies, strategies, and guidelines on insecticide resistance monitoring and management (IRM) over the past decade (2014\u0026ndash;2024). The review focused on documents produced by Tanzania\u0026rsquo;s NMCP, the Ministry of Health (MoH), the World Health Organization (WHO) and malaria control partners. The identification was done through systematic searches of the government and WHO official websites, complemented by searches in PubMed, Google Scholar databases and other scientific repositories. Search terms included combinations of keywords such as \u0026ldquo;malaria vectors\u0026rdquo;, \u0026ldquo;insecticide resistance,\u0026rdquo; \u0026ldquo;vector control\u0026rdquo;, \u0026ldquo;insecticide resistance management,\u0026rdquo; \u0026ldquo;insecticide resistance monitoring\u0026rdquo; and \u0026ldquo;entomological surveillance\u0026rdquo;. Eligible documents included national reports, strategic plans, guidelines, frameworks, and evaluation documents relevant to malaria vector control and resistance management. For WHO documents, those published before 2010 were excluded.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eKey national policy documents were retrieved from the MoH and NMCP websites, including two NMCP Strategic Plans (2014\u0026ndash;2020 and 2021\u0026ndash;2025) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], the Integrated Vector Management Guidelines and Standard Operating Procedures (IVM-SOP) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], the National Guidelines for Integrated Malaria Vector Control (NGIMVC) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], the Malaria Surveillance, Monitoring and Evaluation Plan (MSMEP) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and the National Strategy for Vector Control 2019\u0026ndash;2024 (NSVC) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Searches of WHO databases and scientific repositories identified several complementary global publications, including the Global Plan for Insecticide Resistance Management in Malaria Vectors (GPIRM) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], the Manual for Monitoring Insecticide Resistance in Mosquito Vectors and Selecting Appropriate Interventions [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], the Global Report on Insecticide Resistance in Malaria Vectors [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and the Framework for a National Plan for Monitoring and Management of Insecticide Resistance in Malaria Vectors [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The full list of documents reviewed is included in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of documents reviewed to understand current policies, guidelines and practices of insecticide resistance monitoring and management in Tanzania\u0026rsquo;s malaria control program.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDocument title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrganization\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNational Malaria Strategic Plan 2014\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNMCP, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNational Malaria Strategic Plan 2021\u0026ndash;2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNMCP, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntegrated Vector Management Guidelines \u0026amp; Standard Operating Procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMoH, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNational Guidelines for Integrated Malaria Vector Control (NGIMVC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNMCP, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalaria Surveillance, Monitoring \u0026amp; Evaluation Plan (MSMEP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNMCP, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNational Strategy for Vector Control 2019\u0026ndash;2024 (NSVC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMoH, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTanzania Malaria Indicator Surveys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMoH, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNational Social and Behavior Change and Advocacy Guide for Malaria Interventions 2021\u0026ndash;2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNMCP, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTanzania (Mainland) Malaria Profile FY 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eU.S. PMI, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTanzania (Mainland) Malaria Operational Plan FY 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eU.S. PMI, Tanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobal Plan for Insecticide Resistance Management in Malaria Vectors (GPIRM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManual for Monitoring Insecticide Resistance in Mosquito Vectors and Selecting Appropriate Interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTest procedures for insecticide resistance monitoring in malaria vector mosquitoes (Second edition)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobal Report on Insecticide Resistance in Malaria Vectors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuidelines for Malaria Vector Control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFramework for a National Plan for Monitoring and Management of Insecticide Resistance in Malaria Vectors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorld Malaria Reports 2019\u0026ndash;2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR46 CR47\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: U.S. PMI denotes the United States President\u0026rsquo;s Malaria Initiative; WHO, the World Health Organization; MoH, the Ministry of Health and NMCP, National Malaria Control Programme. All documents were publicly available online at the time of access, were downloaded, and are available from the corresponding author upon request if no longer accessible online.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKey informant interviews\u003c/strong\u003e \u003cp\u003eTo complement the document review, key informant interviews were conducted with policymakers, representatives of funding agencies, field implementers, and technical experts. The policy-level interviewees included representatives of key government agencies, including the NMCP, the President\u0026rsquo;s Office-Regional Administration and Local Government (PO-RALG), the National Institute for Medical Research (NIMR), the Tanzania Plant Health and Pesticides Authority (TPHPA), operating under the Ministry of Agriculture (MoA). Others included representatives of non-governmental organizations, namely US President\u0026rsquo;s Malaria Initiative (PMI), Population Services International (PSI) and the WHO. District and regional level field implementers interviewed included those based in Mwanza, Kigoma, and Tabora regions, where the country was most recently implementing both ITNs and IRS strategies.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e A total of 24 key informant interviews were completed, either in person or virtually (via Zoom) for participants who were unable to join in-person meetings. Of the 24 participants, 18 were males and 6 were females; and all were between 30\u0026ndash;55 years old, and had a tertiary education. The discussions were held primarily in Swahili (Tanzania\u0026rsquo;s main language) with occasional use of English. Subjects covered included participants\u0026rsquo; understanding, perceptions, and opinions on insecticide resistance, insecticide resistance monitoring and management strategies, implementation challenges, and discrepancies between policy and practice.\u003c/p\u003e \u003cp\u003e Each interview lasted between one to two hours and was audio-recorded with participants\u0026rsquo; permission. Recordings were supplemented with detailed field notes to capture contextual observations. Written informed consent was obtained from all participants before data collection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll audio recordings were transcribed word-for-word and thoroughly reviewed to ensure accuracy. To maintain the authenticity and contextual integrity of participants\u0026rsquo; responses, transcripts were retained in original language used during the interview (Swahili). The qualitative data were analyzed using thematic content analysis, employing both deductive and inductive approaches to identify pre-defined major themes and emerging themes. NVivo software (version 15)[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] was used to organize and manage codes, themes, and patterns. The major themes identified included: knowledge and perceptions of insecticide resistance, views on resistance monitoring and surveillance systems, insecticide resistance management strategies, implementation challenges, and discrepancies between policy and actual practice.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eInsights from document review\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eAlignment of national strategies with global IRM frameworks\u003c/h2\u003e \u003cp\u003eThe review of national and international documents revealed that Tanzania has progressively aligned its strategic direction with global frameworks for insecticide resistance monitoring and management (IRM) over the past decade. The NMCP strategic plans (2014\u0026ndash;2020 and 2021\u0026ndash;2025)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] define the core pillars of Tanzania\u0026rsquo;s malaria agenda, including integrated vector control; malaria diagnosis, treatment, and preventive therapies; and surveillance, monitoring, and evaluation. These plans are guided by the national vision of a malaria-free society and a mission to ensure equitable access to high-quality, effective, and affordable malaria services through partnerships and community participation.\u003c/p\u003e \u003cp\u003eIn support of this vision, a suite of policies, frameworks, and technical guidelines have been developed, namely, the Integrated Vector Management Guidelines and Standard Operating Procedures (IVM-SOP) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], the National Guidelines for Integrated Malaria Vector Control (NGIMVC) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], the Malaria Surveillance, Monitoring and Evaluation Plan (MSMEP) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and the National Strategy for Vector Control 2019\u0026ndash;2024 (NSVC) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Collectively, these documents are consistent with WHO recommendations and key global guidance documents, including the Global Plan for Insecticide Resistance Management in Malaria Vectors (GPIRM) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], the Manual for Monitoring Insecticide Resistance in Mosquito Vectors [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], the Global Report on Insecticide Resistance in Malaria Vectors [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and the Framework for a National Plan for Monitoring and Management of Insecticide Resistance in Malaria Vectors [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eIntegrating of the principles of the global plan for insecticide resistance management (GPIRM)\u003c/h2\u003e \u003cp\u003eOverall, the reviewed documents indicate that Tanzania has adopted the major pillars of the GPIRM [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], adapting them to national priorities and operational contexts. In particular, the planning and implementation of IRM strategies, together with systematic surveillance and monitoring of insecticide resistance, are recognized as critical components of the national response. The reviewed frameworks underscore the urgent need for coordinated, proactive, and sustained action to address the increasing threat of resistance, especially in high-burden areas such as the northern, southern, and south-eastern regions of the country as well as the districts bordering Lake Victoria in the north and northwest [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother area of alignment with global recommendations was that Tanzania\u0026rsquo;s national IRM framework also emphasizes both immediate and long-term interventions such as insecticide rotations, combinations, mosaic spraying, and the use of insecticide mixtures [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. More recently, the incorporation of next-generation tools, including piperonyl butoxide (PBO)- ITNs and innovative insecticide formulations for IRS, reflects the country\u0026rsquo;s commitment to maintaining vector susceptibility and prolonging the efficacy of available insecticides. We observed that Tanzania constantly updates its guidelines to match the WHO pronouncements, and that both the international and national documents constitute the foundation for the planning, execution, and evaluation of integrated vector control interventions.\u003c/p\u003e \u003cp\u003eLastly, the document review found strong alignment with WHO\u0026rsquo;s standardized guidelines for insecticide resistance monitoring [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], which advocate the use of validated bioassays, prioritization of key vectors and insecticides for testing, and adaptation of control interventions based on resistance data [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGaps between policy and implementation\u003c/h3\u003e\n\u003cp\u003eDespite this strong policy alignment, the review identified persistent gaps between strategic intent and implementation outcomes. The reviews highlight that resource limitations, logistical challenges, and operational inefficiencies continue to hinder full realization of planned activities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. It was noted that only 22 of the 62 sentinel districts chosen for malaria vector surveillance have been used to monitor insecticide resistance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which makes the national resistance profile less representative.\u003c/p\u003e \u003cp\u003eThese shortfalls were attributed to delays in ITN distribution, high operational costs of the operations, inadequate financing, and gaps in human and infrastructural capacity, all of which collectively result in suboptimal intervention coverage and limited protection for at-risk populations.\u003c/p\u003e\n\u003ch3\u003eInsights from in-depth key informant interviews\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge and perception on insecticide resistance\u003c/h2\u003e \u003cp\u003eMost respondents had a good understanding of insecticide resistance and its impact on malaria control. Some linked it to antimicrobial resistance, and others said that the use of pesticides in farming was a major cause of resistance because the agricultural pesticides are of similar classes to public health insecticides. However, regarding resistance levels and spread in Tanzania, most respondents were unable to provide specific information, citing a lack of accessible statistical data. The quotes below provide further insights:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003ePesticides used in agriculture are also applied in public health, exposing mosquitoes to the same insecticides. This repeated exposure can cause the development of insecticide resistance in vector populations\u0026hellip;\u003c/em\u003e\u0026rdquo; (Male participant, district-level field implementer).\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; yes, insecticide resistance is a growing problem. It was once limited to a few areas but has now spread. Although I don\u0026rsquo;t have enough data, but the problem is serious\u0026rdquo;\u003c/em\u003e (Male participant, regional-level field implementer).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInsecticide resistance monitoring and management\u003c/h2\u003e \u003cp\u003eAccording to the expert respondents, insecticide resistance monitoring in Tanzania began in 1999, initially focusing on testing the susceptibility of primary malaria vectors to pyrethroids using WHO insecticide susceptibility assays. Over time, the programme has expanded from a few sites to 22 out of 184 sentinel councils nationwide, with a strategic shift to prioritize districts with high malaria prevalence. However, most respondents noted that this coverage is not nationally representative, making it difficult to generalize the findings to the entire country:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;if we had at least one monitoring site in each region, it would improve the representativeness. We can\u0026rsquo;t reach every area, but covering more councils would give a better national picture. Right now, we talk about representation, but it\u0026rsquo;s difficult to claim that 22 councils represent the situation in all 184\u0026hellip;\u0026rdquo;\u003c/em\u003e (Male participant, technical expert)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;...currently, we have about 184 or 185 councils, if I\u0026rsquo;m not mistaken, but resistance monitoring is conducted in only 22. I believe this coverage is too small to adequately represent the insecticide resistance problem across the entire country\u0026rdquo;\u003c/em\u003e (Female participant, representative of funding agency).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDiscrepancy in policy and practice\u003c/h2\u003e \u003cp\u003eNearly all respondents stated that there were discrepancies between policy and actual practice. They attributed these gaps to factors such as funding and resource constraints, coordination challenges, and shortages of trained personnel. For example, although Tanzania\u0026rsquo;s current policy recommends deploying multiple interventions using insecticides with different modes of action, such as rotating organophosphates and neonicotinoids for IRS, the stakeholders interviewed here indicated that these stipulated strategies have not been effectively implemented. It was also stated that while insecticide rotations had been the most widely practiced strategy historically, specifically in the districts receiving IRS, this was no longer the case as the practice of IRS had been significantly reduced in Tanzania:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026hellip;yes, I can say that there is a clear discrepancy between policy and actual practice in the field, largely due to limited resources. The government depends heavily on external funding; as a result, certain interventions, such as IRS, cannot be implemented as prescribed in the policy, particularly after donor support for IRS was withdrawn\u003c/em\u003e (Male respondent, policymaker).\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Rotation was the most used method, but now it is combination. This was possible due to IRS, but with IRS gone, rotation is no longer used, though it was very effective\u0026rdquo;\u003c/em\u003e (Male participant, district-level field implementer).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eConcerns related to limited financing as a barrier to effective implementation of insecticide resistance monitoring and management strategies\u003c/em\u003e \u003c/p\u003e \u003cp\u003eNearly all respondents identified inadequate financing as a primary barrier to effective implementation. Many noted that although ITNs are intended to be replaced every three years, logistical challenges and funding shortfalls frequently delay distributions, extending replacement cycle:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;our policies are well-designed and clearly articulated; however, the main challenge lies in the lack of funding to implement what is outlined in the policy\u0026rdquo;\u003c/em\u003e (Female respondent, policymaker).\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;the main challenge is funding. If NMCP had its own allocated budget from the government, clearly defined with set amounts for specific needs like net procurement, I don\u0026rsquo;t think there would be such difficulty in implementation\u0026rdquo;\u003c/em\u003e (Male respondent, technical expert).\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eYou order the insecticide (biolarvicides) to arrive during the dry season when breeding sites are easily identifiable, but the funds are disbursed during the peak of the rainy season\u003c/em\u003e\u0026rdquo; (Male respondent, district-level field implementer).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe respondents also emphasized that, the country is highly depending on donor funds to ensure availability of malaria prevention interventions. They noted that such dependency affects the availability on interventions but also impacts on the selection of appropriate interventions, which they argued is more likely to reflect donor\u0026rsquo;s and not country preference:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;but most delays are due to reliance on external funding sources, which come with their own bureaucratic procedures that must be followed before funds are released. That\u0026rsquo;s where the discrepancies arise\u003c/em\u003e\u0026rdquo; (Male respondent, regional-level field implementer).\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003e\u0026hellip;much of the fight against malaria is donor-funded, if I'm not mistaken, since around 1999. I wonder what our situation will be if they will fully withdraw their support...\u0026rdquo;\u003c/em\u003e (Male participant, technical expert)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;One among the challenges for not being able to implement what is indicated within the policy is presence of a lot of priorities at regional and district levels, which inhibit allocation of enough funds for malaria prevention activities\u0026rdquo;\u003c/em\u003e (Female respondent, district-level field implementer).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMajority of respondents highlighted the need to mobilize domestic resources to address current funding gaps. They also recommended active engagement of local stakeholders and allocation of revenues from national natural resources, such as mining sectors to strengthen investments in vector control:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWe have abundant natural resources, including mines like Geita Gold Mining and Lakes. Why are we not allocating revenue from these resources to support malaria elimination and resistance management efforts?\u0026rdquo;\u003c/em\u003e (Male participant, regional-level field implementer).\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I believe internal funds exist in abundance; it's just a matter of priority. For example, a single wealthy individual and banks like CRDB and NMB can spend a lot of money sponsoring football leagues. I'm not saying it's not important; it is, but the same funders could also be encouraged to support public health initiatives. So why aren\u0026rsquo;t they being engaged in malaria prevention and elimination efforts\u003c/em\u003e?\u0026rdquo; (Male participant, technical expert).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eConcerns related to poor coordination and shortage of trained personnel\u003c/h2\u003e \u003cp\u003eRespondents identified several additional challenges, including bureaucratic delays in fund disbursement to local councils and poor coordination of roles and activities. In Tanzania, although policies are formulated at the national level, implementation occurs at the council level, where guidelines are often distributed but insufficiently disseminated, leading to limited ownership among implementers. Some participants noted overlapping or unclear responsibilities between the Ministry of Health (MoH) and the President\u0026rsquo;s Office-Regional Administration and Local Government (PO-RALG): the MoH develops policies and strategic plans, while PO-RALG oversees implementation. This structural arrangement has resulted in sub-optimal engagement of district-level operators, fund misallocation, staffing challenges, and a top-down approach that limits input from local implementers. This has also contributed to delays in execution of insecticide resistance management activities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe main challenge causing discrepancies is the communication gap between national policymakers and council-level implementers. Plans are made at the top, but implementation happens at the grassroots...\u0026rdquo;\u003c/em\u003e (Male respondent, regional-level field implementer).\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I would say the guidelines are distributed but not effectively disseminated, which cause some local implementers to lose their sense of ownership\u0026hellip;\u0026rdquo;\u003c/em\u003e (Female respondent, district-level field implementer).\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;for example, I assessed the larvicide needs in my council, including coverage and costs, totaling nearly 22\u0026nbsp;million TZS. However, I was later informed during a regional meeting that only 4.5\u0026nbsp;million TZS was available. I was left wondering how to proceed...\u0026rdquo;\u003c/em\u003e (Male respondent, district-level field implementer).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother concern was the lack of formal recognition for personnel trained at the Vector Control Training Centre (VCTC) in Tanga, whose salaries remain at volunteer level despite completing two to three years of specialized training. Accordingly, respondents stressed that, alongside regular training and proper coordination, which are essential for effective insecticide resistance management, policymakers should actively disseminate guidelines and provide context-specific training to local implementers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...regular trainings are essential and I suggest that those staff who attended the training at our college in Tanga (Vector Control Training Centre), should be considered for appropriate salary scale categorization to enhance their motivation, \u0026hellip;every district should have a dedicated vector control specialist, such as an entomologist, to strengthen vector control efforts at the district level, unlike the current situation\u0026rdquo;\u003c/em\u003e (Male participant, district-level field implementer).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInadequate community malaria education and engagement\u003c/h2\u003e \u003cp\u003eRespondents identified insufficient community-based malaria education as a key factor widening the policy-practice gap. Participants stressed that malaria elimination demands robust community engagement and culturally tailored behavior change communication. Educated communities are more apt to sustain preventive practices, such as using insecticide-treated nets and managing mosquito breeding sites. Additionally, involving religious and political leaders as advocates was considered vital for community mobilization, perception shifting, and widespread adoption of malaria prevention and resistance management strategies:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;. to ensure successful elimination, we should also invest in behavior change design and campaigns aimed at altering community perceptions on malaria and interventions, tailored to the specific characteristics of each region..\u0026rdquo;\u003c/em\u003e (Male participant, regional-level field implementer).\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Once a person is educated, even the interventions you plan to introduce become much easier to implement and use. Therefore, in the fight against malaria, we must invest significantly in educating the community. I believe that if the community is fully educated, the malaria problem can be reduced to more than 50%\u0026rdquo;\u003c/em\u003e (Male participant, technical expert).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePerceptions on the current malaria control targets\u003c/h2\u003e \u003cp\u003eWhen asked about the adequacy of current strategies and tools to address insecticide resistance and achieve malaria elimination by 2030, most respondents expressed skepticism. The discontinuation of IRS and limited support for biolarviciding were viewed as major barriers to sustaining progress.\u003c/p\u003e \u003cp\u003eParticipants agreed that achieving elimination targets will require reduced dependence on external funding and increased domestic resource mobilization. They emphasized the need to elevate malaria control and IRM to national priorities, comparable to the country\u0026rsquo;s response to other major diseases such as HIV/AIDS. Strengthening intersectoral collaboration, particularly among the Ministry of Health (MoH), Ministry of Agriculture (MoA), and the Ministry of Infrastructure, was also identified as essential to advancing national malaria elimination efforts\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; eliminating malaria by 2030 is like a dream; let\u0026rsquo;s be honest. It will only be possible with blanket larviciding; otherwise, it remains just a dream. Even regions with less than 1% malaria prevalence are simply benefiting from colder climates that are unfavorable for mosquito breeding\u0026rdquo;\u003c/em\u003e (Male participant, regional-level field implementer).\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eDue to the withdrawal of the IRS and the lack of donor support for biolarviciding, achieving the goal of reducing transmission by 90% and mitigating resistance will be highly challenging\u003c/em\u003e\u0026rdquo; (Female participant, technical expert).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the alignment between national policies and on-the-ground implementation of insecticide resistance management strategies in Tanzania\u0026rsquo;s malaria control ecosystem. It critically evaluated national insecticide resistance monitoring and management (IRM) strategies and identified key barriers and policy-practice gaps. Although the NMCP has established comprehensive frameworks consistent with WHO recommendations, substantial implementation challenges remain. These challenges stem from limited resources, constrained surveillance coverage, reliance on external funding, and weak coordination across administrative levels. While these challenges are not unique to Tanzania, similar obstacles are widely documented across malaria-endemic countries in sub-Saharan Africa, where the transition from policy formulation to effective operationalization remains a major bottleneck in resistance management and vector control [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR51 CR52\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The findings from this study highlight the urgent need for stronger domestic financing, improved multisectoral collaboration, and sustained community engagement to ensure that national policy commitments translate into measurable progress toward malaria elimination.\u003c/p\u003e \u003cp\u003ePersistent funding and resource constraints, coupled with heavy donor dependence, pose major challenges to effective IRM and malaria elimination. Over the past decade, more than two-thirds of malaria control investments in endemic countries have relied on external funding. In Tanzania, approximately 90% of malaria financing is provided by the Global Fund (GF) and the President\u0026rsquo;s Malaria Initiative (PMI), contributing an estimated USD 265\u0026nbsp;million during 2021\u0026ndash;2023 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, a funding gap exceeding USD 200\u0026nbsp;million remains for the 2021\u0026ndash;2025 strategic plan [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While these partnerships have enhanced program efficiency and targeted resource allocation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR55\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], delays linked to procurement and tendering processes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] underscore the vulnerabilities of donor dependence. Consistent with prior studies highlighting the pivotal role of internal financing in malaria control [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR59\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], this study underscores the critical importance of strengthening domestic resource mobilization to ensure sustainable malaria control and elimination, particularly amid recent donor funding cuts from agencies such as USAID [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Although Tanzania\u0026rsquo;s economy may not yet match international contributions [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], increasing domestic financing could strengthen IRM implementation by expanding surveillance and monitoring coverage and enabling the effective deployment of previously abandoned, donor-unsupported strategies such as IRS and larviciding [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeyond funding, enhanced community engagement and education, improved coordination, adequate human resources, and effective decentralization of health services are critical for successful malaria control interventions [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan additionalcitationids=\"CR64 CR65\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Our study underscores that engaging influential community figures, such as religious leaders, local chiefs, and politicians, can strengthen IRM implementation and advance malaria elimination goals. Consistent with previous evidence [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan additionalcitationids=\"CR68 CR69\" citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], community acceptability and participation are pivotal to the success of interventions, as they cultivate local ownership and sustainability. Ensuring that communities are meaningfully engaged throughout planning, implementation, and dissemination phases allows their priorities and concerns to be addressed, which enhances acceptance and uptake [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. This is particularly important given ongoing efforts by the NMCP to expand knowledge and awareness of malaria and its interventions within Tanzanian communities [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Furthermore, robust intersectoral collaboration, strengthened institutional coordination, and a well-trained health workforce equipped with continuous professional development and policy guidance are equally vital for sustaining effective IRM implementation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR73\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to provide additional insights to support ongoing IRM strategies and was not intended to alter NMCP or partner efforts in malaria control. It acknowledges the success of national policies emphasizing routine resistance monitoring, evidence-based vector control, and insecticide rotation aligned with global IRM frameworks [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The national monitoring system, despite covering few sites, has produced high-quality resistance data, demonstrating the NMCP\u0026rsquo;s strong commitment to surveillance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Similarly, insecticide management strategies, including rotating non-pyrethroid insecticides for IRS and transitioning to next-generation ITNs, have successfully restored mosquito susceptibility in several regions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, implementation has been inconsistent, particularly following IRS withdrawal and recent funding reductions [\u003cspan additionalcitationids=\"CR76 CR77\" citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. This study highlights the urgent need to address implementation barriers to ensure effective insecticide resistance management and malaria control. Consistent with existing evidence on the role of non-pyrethroid interventions in managing resistance [\u003cspan additionalcitationids=\"CR80 CR81 CR82 CR83\" citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e], the findings also underscore the importance of reintroducing non-pyrethroid IRS where appropriate and fully implementing complementary measures such as larviciding. We propose recommendations (Table\u0026nbsp;2) to strengthen IRM implementation and accelerate malaria elimination in Tanzania.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Summary of recommendations to address the challenges hindering the effective IRM and malaria elimination efforts in Tanzania\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3131%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChallenge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73.4388%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecommendation(s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3131%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunding and resource constraints, and donor dependence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.4363%;\"\u003e\n \u003cp\u003eIncrease domestic funding and resource mobilization through public-private partnerships, improved taxation, health levies, innovative tools such as diaspora bonds, and efficient use of natural resource revenues\u003c/p\u003e\n \u003cp\u003eEnhance governance, transparency, and accountability, while reducing corruption\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3131%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePoor coordination and shortage of trained personnel\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.4363%;\"\u003e\n \u003cp\u003eEstablish a well-defined coordination unity for IRM with a clear mandate and dedicated budget\u003c/p\u003e\n \u003cp\u003eDisseminate guidelines and provide context-specific training to local implementers\u003c/p\u003e\n \u003cp\u003eRevise salary scales for VCTC-trained vector control staff at regional and district levels to improve motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3131%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInadequate community malaria education and engagement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.4363%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale up community engagement and culturally tailored behavior change campaigns involving e\u003c/strong\u003entire community, religious leaders, local chiefs and politicians\u003c/p\u003e\n \u003cp\u003eIntegrate malaria education into school curricula and existing media platforms, including television and radio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003c/br\u003e\u003cp\u003eDespite the novelty of this study, its findings should not be generalized to other health issues or sectors, as it is limited to examining challenges and gaps in implementing vector control strategies in Tanzania within the context of insecticide-resistance monitoring and management. The analysis reflects policies and implementation practices at a specific point in time and may not capture recent policy changes or ongoing initiatives. Although the number of in-depth interviews was relatively small and drawn from a few regions, efforts were made to engage key stakeholders, including policymakers, funders, technical experts, and implementers at both regional and district levels, who are representative of the target group. In addition, while the document review was constrained by the availability of publicly accessible policy materials, the inclusion of relevant documents from the NMCP and WHO strengthened the study\u0026rsquo;s contextual validity and relevance.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides compelling evidence that, although Tanzania\u0026rsquo;s malaria control frameworks align with global best practices, their implementation remains constrained by persistent operational and systemic challenges. These include funding shortfalls, donor reliance, limited capacity, weak coordination, low community engagement, poor intersectoral collaboration, and sociocultural barriers. These challenges threaten progress toward malaria elimination by 2030. Addressing these policy-practice gaps in insecticide resistance management will require sustained financing, stronger coordination, expanded surveillance, and enhanced community and intersectoral participation. Prioritizing these actions is critical not only for effective resistance management but also for realizing the national goal of a malaria-free Tanzania.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the members of NMCP, NIMR, IHI, PO-RALG, TPHPA, PSI, PMI, WHO and implementers from Mwanza, Kigoma and Tabora regions for their valuable participation in this study. We are also grateful for the support provided by the OMC team at IHI and by Heka Mapunda of TTCIH.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHEG, MMM, YPM, HSN, PS and FOO designed and conceptualized the study. HEG, IRM, IHN, GGS, RMN, SSM, RPN and CDM involved in data collection and analysis. HEG and IRM wrote initial and subsequent drafts of the manuscript. MMM, YPM, IRM, HSN, PS and FOO supervised the study and reviewed the study protocols and all drafts of the manuscript. All authors revised the final manuscript and approved the submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Institutional Review Board (IRB) of the Ifakara Health Institute (IHI/IRB/EXT/No: 44-2024) and from the Medical Research Coordination Committee of the National Institute for Medical Research (NIMR), Tanzania (NIMR/HQ/R.8c/Vol.I/2937).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors agreed to publish this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Gates Foundation through the African Consortium in Modelling for Effective Vector Control (ACoMVeC) project (grant no. INV-047049). The funder had no role in the study design, data collection, analysis, manuscript preparation or publication decision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCharles D. Mwalimu and Rosemary P. Nshama\u003csup\u003e\u0026nbsp;\u003c/sup\u003eare affiliated with the National Malaria Control Programme (NMCP). The authors declare no other conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available from the corresponding author(s) upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eNelson Mandela African Institution of Science and Technology (NM-AIST), P.O. Box 447, Arusha, Tanzania. \u003csup\u003e2\u003c/sup\u003e Environmental Health and Ecological Science Department, Ifakara Health Institute, P.O. Box 53, Ifakara, Tanzania.\u003csup\u003e\u0026nbsp;3\u003c/sup\u003eDepartment of Mathematics and Statistics, University of Dodoma, P.O. Box 338, Dodoma, Tanzania. \u003csup\u003e4\u003c/sup\u003eInstitute for Diseases Modeling, Gates Foundation, Global Health Division, Seattle, Washington, United States of America. \u003csup\u003e5\u003c/sup\u003eSchool of Biodiversity, One Health and Veterinary Medicine, G12 8QQ, University of Glasgow, Glasgow, UK \u0026amp; \u003csup\u003e6\u003c/sup\u003eNational Malaria Control Programme (NMCP), Dodoma, Tanzania.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. World malaria report 2024: Addressing inequity in the global malaria response. Geneva: World Health Organization; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. WHO guidelines for malaria. Geneva: World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Seventeenth Meeting of the WHO Vector Control Advisory Group Meeting Report. Geneva: World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkumu F, Gyapong M, Casamitjana N, Castro MC, Itoe MA, Okonofua F, et al. What Africa can do to accelerate and sustain progress against malaria. PLOS Glob Public Health. 2022;2:e0000262.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. WHO recommends R21/Matrix-M vaccine for malaria prevention in updated advice on immunization. Geneva: World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatt S, Weiss DJ, Cameron E, Bisanzio D, Mappin B, Dalrymple U, et al. The effect of malaria control on \u003cem\u003ePlasmodium falciparum\u003c/em\u003e in Africa between 2000 and 2015. Nature. 2015;526:207\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindsay SW, Thomas MB, Kleinschmidt I. Threats to the effectiveness of insecticide-treated bednets for malaria control: thinking beyond insecticide resistance. Lancet Glob Health. 2021;9:e1325\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLandier J, Parker DM, Thu AM, Carrara VI, Lwin KM, Bonnington CA, et al. The role of early detection and treatment in malaria elimination. Malar J. 2016;15:363.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. World malaria report 2023: Tracking progress and gaps in the global response to malaria. Geneva:World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Malaria Control Programme. National Malaria Strategic plan 2021\u0026ndash;2025 Transitioning to Malaria Elimination in Phases. Tanzania. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nmcp.go.tz/publication\u003c/span\u003e\u003cspan address=\"https://www.nmcp.go.tz/publication\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 13 Apr 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClyde DF. Malaria control in Tanganyika under the German Administration. I. E. East Afr Med J. 1961;38:27\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurshen M. The impact of colonialism on health and health services in Tanzania. Int J Health Serv. 1977;7:7\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYhdego M, Majura P. Malaria control in Tanzania. Environ Int Pergamon. 1988;14:479\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulkarni MA, Malima R, Mosha FW, Msangi S, Mrema E, Kabula B, et al. Efficacy of pyrethroid-treated nets against malaria vectors and nuisance-biting mosquitoes in Tanzania in areas with long-term insecticide-treated net use. Trop Med Int Health. 2007;12:1061\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. RBM-progress and impact series: country reports: focus on mainland Tanzania. Geneva: World Health Organization; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaldas De Castro M, Yamagata Y, Mtasiwa D, Tanner M, Utzinger J, Keiser J, et al. Integrated urban malaria control: a case study in Dar es salaam, Tanzania. Am J Trop Med Hyg. 2004;71:103\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTungu P, Kabula B, Nkya T, Machafuko P, Sambu E, Batengana B, et al. Trends of insecticide resistance monitoring in mainland Tanzania, 2004\u0026ndash;2020. Malar J. 2023;22:1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health Community Development Gender Elderly and Children [Tanzania Mainland]. Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS) Office of the Chief Government Statistician, and ICF. \u003cem\u003eTanzania Malaria Indicator Survey 2017\u003c/em\u003e. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: MoHCDGEC, MoH, NBS, OCGS, and ICF; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health (MoH). [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), ICF. \u003cem\u003eTanzania Demographic and Health Survey and Malaria Indicator Survey 2022 Final Report\u003c/em\u003e. Dodoma, Tanzania, and Rockville, Maryland, USA: MoH, NBS, OCGS, and ICF; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabula B, Mlacha YP, Serbantez N, Nhiga SL, Mkude S, Kiware S, et al. Pyrethroid-resistant malaria vector \u003cem\u003eAnopheles gambiae\u003c/em\u003e restored susceptibility after pre-exposure to piperonyl-butoxide: results from country-wide insecticide resistance monitoring in Tanzania, 2023. Malar J. 2024;23:1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMwalimu CD, Kiware S, Nshama R, Derua Y, Machafuko P, Gitanya P et al. Dynamics of malaria vector composition and \u003cem\u003ePlasmodium falciparum\u003c/em\u003e infection in mainland Tanzania: 2017\u0026ndash;2021 data from the national malaria vector entomological surveillance. Malar J. 2024;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSokhna C, Ndiath MO, Rogier C. The changes in mosquito vector behaviour and the emerging resistance to insecticides will challenge the decline of malaria. Clin Microbiol Infect. 2013;19:902\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOdero JO, Nambunga IH, Masalu JP, Mkandawile G, Bwanary H, Hape EE, et al. Genetic markers associated with the widespread insecticide resistance in malaria vector \u003cem\u003eAnopheles funestus\u003c/em\u003e populations across Tanzania. Parasit Vectors. 2024;17:230.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMnzava AP, Knox TB, Temu EA, Trett A, Fornadel C, Hemingway J, et al. Implementation of the global plan for insecticide resistance management in malaria vectors: Progress, challenges and the way forward. Malar J. 2015;14:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNjau RJA, De Savigny D, Gilson L, Mwageni E, Mosha FW. Implementation of an insecticide-treated net subsidy scheme under a public-private partnership for malaria control in Tanzania - Challenges in implementation. Malar J. 2009;8:1\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMlozi Malongo R, Susan M, Tabitha B, Veneranda S, Elizabeth M, Benjamin et al. Challenges and opportunities for implementing an intersectoral approach in malaria control in Tanzania. Tanzan J Health Res. 2015; 17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMwendera CA, De Jager C, Longwe H, Kumwenda S, Hongoro C, Phiri K, et al. Challenges to the implementation of malaria policies in Malawi. BMC Health Serv Res. 2019;19:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen JM, Okumu F, Moonen B. The fight against malaria: Diminishing gains and growing challenges. Sci Transl Med. 2022;14:eabn3256.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlonso PL, Tanner M. Public health challenges and prospects for malaria control and elimination. Nat Med. 2013;19:150\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Malaria Control Programme. National Malaria Strategic Plan 2014\u0026ndash;2020, Abridged Version. Tanzania. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nmcp.go.tz/publication\u003c/span\u003e\u003cspan address=\"https://www.nmcp.go.tz/publication\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 13 Apr 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Global Plan for Insecticide Resistance Management in Malaria Vectors: executive summary. Geneva: World Health Organization; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. Integrated Vector Management Guidelines and Standard Operating Procedures. Tanzania. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nmcp.go.tz/publication\u003c/span\u003e\u003cspan address=\"https://www.nmcp.go.tz/publication\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 Feb 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKailembo D, Gavana T, Kasagama E, Bernard J, Molteni F, Kisoka N, et al. Large-scale intermittent larviciding intervention and associations with key malaria epidemiological parameters in Tanga Region, Tanzania. Malar J. 2025;24:350.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Malaria Control Programme. National Guidelines for Integrated Malaria Vector Control. Tanzania. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nmcp.go.tz/publication\u003c/span\u003e\u003cspan address=\"https://www.nmcp.go.tz/publication\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 12 Mar 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Malaria Control Programme. Malaria Surveillance, Monitoring and Evaluation Plan, 2021\u0026ndash;2025. Tanzania. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nmcp.go.tz/publication\u003c/span\u003e\u003cspan address=\"https://www.nmcp.go.tz/publication\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 14 Apr 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. National Strategy for Vector Control 2019\u0026ndash;2024. Tanzania. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.moh.go.tz/report\u003c/span\u003e\u003cspan address=\"https://www.moh.go.tz/report\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 Apr 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Manual for monitoring insecticide resistance in mosquito vectors and selecting appropriate interventions. Geneva: World Health Organization; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Global report on insecticide resistance in malaria vectors: 2010\u0026ndash;2016. Geneva: World Health Organization; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Framework for a national plan for monitoring and management of insecticide resistance in malaria vectors. Geneva: World Health Organization; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Malaria Control Programme. National Social and Behavour Change \u0026amp; Advocacy Guide for Malaria Interventions 2021\u0026ndash;2025. Tanzania; 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.nmcp.go.tz/publication\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 15 Apr 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. President\u0026rsquo;s Malaria Initiative. Tanzania (Mainland) Malaria Profile FY 2023. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mesamalaria.org/wp-content/uploads/2025/04/TANZANIA-MAINLAND-Malaria-Profile-PMI-FY-2024.pdf\u003c/span\u003e\u003cspan address=\"https://mesamalaria.org/wp-content/uploads/2025/04/TANZANIA-MAINLAND-Malaria-Profile-PMI-FY-2024.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 13 Mar 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. President\u0026rsquo;s Malaria Initiative. Tanzania (Mainland) Malaria Operational Plan FY 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://reliefweb.int/report/united-republic-tanzania/presidents-malaria-initiative-tanzania-malaria-operational-plan-fy-2023\u003c/span\u003e\u003cspan address=\"https://reliefweb.int/report/united-republic-tanzania/presidents-malaria-initiative-tanzania-malaria-operational-plan-fy-2023\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 11 Feb 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Test procedures for insecticide resistance monitoring in malaria vector mosquitoes (Second edition). Geneva: World Health Organization; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Guidelines for Malaria Vector Control. Geneva: World Health Organization; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. World malaria report 2022: Tracking progress and gaps in the global response to malaria. Geneva: World Health Organization; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. World malaria report 2021: Tracking progress against malaria. Geneva: World Health Organization; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. World Malaria Report 2020: 20 years of global progress \u0026amp; challenges. Geneva: World Health Organization; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. World malaria report 2019. Geneva: World Health Organization; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllsop DB, Chelladurai JM, Kimball ER, Marks LD, Hendricks JJ. Qualitative Methods with Nvivo Software: A Practical Guide for Analyzing Qualitative Data. Psych. 2022;4:142\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWin Han Oo, Nguyen XT, Ngo TVA, Ngo DT, Win Htike, Aye Tun N, et al. Performance and feasibility of reactive surveillance and response strategies for malaria elimination in Vietnam: a mixed-methods study. Malar J. 2023;22:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTabue RN, Gbalegba CGN, Mwalimu CD, Tungu PK, Fodjo BK, Elanga-Ndille E, et al. Managing insecticide resistance in malaria vectors in Africa: case studies from Cameroon, C\u0026ocirc;te d\u0026rsquo;Ivoire and Tanzania. Malar J. 2025;24:1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Implementation of Indoor Residual Spraying of Insecticides for Malaria Control in the WHO African Region Report. Geneva:World Health Organization; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuuron VM, Mwanri L, Tsourtos G, Owusu-Addo E. An exploratory study of the acceptability of indoor residual spraying for malaria control in upper western Ghana. BMC Public Health. 2020;20:465.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarbour C, Hempstone H, Brasington A, Agha S. How donors can collaborate to improve reach, quality, and impact in social and behavior change for health. Glob Health Sci Pract. 2021;9:246\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra V. The Role and Importance of External Donor-Funded DFI\u0026rsquo;s. In: Kararach G, MEP MV, editors. The Palgrave Handbook of Development Finance. Cham: Palgrave Macmillan; 2025. pp. 285\u0026ndash;305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParkhurst J, Ghilardi L, Webster J, Snow RW, Lynch CA. Competing interests, clashing ideas and institutionalizing influence: insights into the political economy of malaria control from seven African countries. Health Policy Plan. 2021;36:35\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKollipara A, Moonasar D, Balawanth R, Silal SP, Yuen A, Fox K, et al. Mobilizing resources with an investment case to mitigate cross-border malaria transmission and achieve malaria elimination in South Africa. Glob Health Action. 2023;16:2205700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkumu F, Odero JO, Charlwood JD, Knols BGJ, Monroe A. Safeguarding malaria control gains in Africa through \u0026lsquo;species sanitation\u0026rsquo; and structural resilience. Trends Parasitol. 2025;41:720\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfrica CDC. Africa\u0026rsquo;s Health Financing in a New Era: Concept Paper. Addis Ababa: Centers for Disease Control and Prevention; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOladipo HJ, Tajudeen YA, Oladunjoye IO, Yusuff SI, Yusuf RO, Oluwaseyi EM, et al. Increasing challenges of malaria control in sub-Saharan Africa: Priorities for public health research and policymakers. Ann Med Surg (Lond). 2022;81:104366.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatindo AY, Meshi EB, Kapologwe NA, Kengia JT, Kajange S, Chaki P, et al. Biolarviciding implementation in southern Tanzania: Scalability opportunities and challenges. PLoS ONE. 2022;17:e0273490.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas Mori A, Christopher Bulula N, Magodi R, Mwengee W. Domestic funding opportunities for Tanzania as five new Middle-Income countries brace for reduced Gavi support for immunization. Vaccine. 2022;40:3278\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoshi IR, Ngowo H, Dillip A, Msellemu D, Madumla EP, Okumu FO, et al. Community perceptions on outdoor malaria transmission in Kilombero Valley, Southern Tanzania. Malar J. 2017;16:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMswati IK. An Africa free of malaria. Lancet. 2019;394:988\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMapua SA, Finda MF, Nambunga IH, Msugupakulya BJ, Ukio K, Chaki PP, et al. Addressing key gaps in implementation of mosquito larviciding to accelerate malaria vector control in southern Tanzania: results of a stakeholder engagement process in local district councils. Malar J. 2021;20:1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOxman AD, Lewin S, Lavis JN, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 15: Engaging the public in evidence-informed policymaking. Health Res Policy Syst. 2010;10:520\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinda MF, Moshi IR, Monroe A, Limwagu AJ, Nyoni AP, Swai JK et al. Linking human behaviours and malaria vector biting risk in south-eastern Tanzania. PLoS ONE. 2019;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaltzell K, Harvard K, Hanley M, Gosling R, Chen I. What is community engagement and how can it drive malaria elimination? Case studies and stakeholder interviews. Malar J. 2019;18:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBardosh K, Desir L, Jean L, Yoss S, Poovey B, Nute A, et al. Evaluating a community engagement model for malaria elimination in Haiti: lessons from the community health council project (2019\u0026ndash;2021). Malar J. 2023;22:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkumu F, Moore SJ, Selvaraj P, Yafin AH, Juma EO, Shirima GSG, et al. Elevating larval source management as a key strategy for controlling malaria and other vector-borne diseases in Africa. Parasit Vectors. 2025;18:1\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBartumeus F, Costa GB, Eritja R, Kelly AH, Finda M, Lezaun J, et al. Sustainable innovation in vector control requires strong partnerships with communities. PLoS Negl Trop Dis Public Libr Sci. 2019;13:e0007204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObeagu EI, Obeagu GU. Emerging public health strategies in malaria control: innovations and implications. Ann Med Surg (Lond). 2024;86:6576\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandler CIR, Jones C, Boniface G, Juma K, Reyburn H, Whitty CJM. Guidelines and mindlines: Why do clinical staff over-diagnose malaria in Tanzania? A qualitative study. Malar J. 2008;7:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRulisa A, van Kempen L, Hakizimana E, Koenraadt CJM. Local resource mobilization for malaria vector control among Rwandan rice farmers: a pilot study into the role of community ownership. J Health Popul Nutr. 2023;42:1\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMwalimu C, Lazaro S, Kisinza W, Magesa S, Kiware S. The impact of Indoor Residual Spraying (IRS) withdrawal in the Lake Zone Regions in Mainland Tanzania. Should Tanzania withdrawal its IRS program? 2023; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21203/rs.3.rs-2888818/v1\u003c/span\u003e\u003cspan address=\"10.21203/rs.3.rs-2888818/v1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSohel MdS. How USAID Budget Cuts Threaten Global Health System. DIU J Allied Health Sci. 2024;11:14\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMbah Ruth H, Caden M, Drusilla N, Alyssa, Russell Jordan. The Impact of USAID Budget Cuts on Global Development Initiatives: A Review of Challenges, Responses, and Implications. Adv Soc Sci Res J. 2025; 12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussein S, Samet JM. Measuring population health impact of the Trump administration\u0026rsquo;s withdrawal from WHO and cuts to USAID: time to start counting. Popul Health Metr. 2025;23:13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBisanzio D, Ally M, Ali AS, Kitojo C, Serbantez N, Kisinza WN, et al. Modelling insecticide resistance of malaria vector populations in Tanzania. Am J Trop Med Hyg. 2022;107:308\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eA\u0026iuml;kpon R, Agossa F, Oss\u0026egrave; R, Oussou O, A\u0026iuml;zoun N, Ok\u0026eacute;-Agbo F, et al. Bendiocarb resistance in \u003cem\u003eAnopheles gambiae s.l.\u003c/em\u003e populations from Atacora department in Benin, West Africa: a threat for malaria vector control. Parasit Vectors. 2013;6:192.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDandi-Labou J, Kengne-Ouafo JA, Mugenzi L, Tchouakui M, Wondji M, Wondji CS. Susceptibility profile of \u003cem\u003eAnopheles\u003c/em\u003e and target site resistance mechanism against organophosphates in Cameroon. PLoS ONE. 2025;20:e0321825.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZoungb\u0026eacute;dji DM, Padonou GG, Konkon AK, Hougbe S, Sagbohan H, Kpanou C, et al. Assessing the susceptibility and efficacy of traditional neurotoxic (pyrethroid) and new-generation insecticides (chlorfenapyr, clothianidin, and pyriproxyfen), on wild pyrethroid-resistant populations of \u003cem\u003eAnopheles gambiae\u003c/em\u003e from southern Benin. Malar J. 2023;22:245.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGervas HE, Mayengo MM, Mlacha YP, Ngowo HS, Okumu FO, Selvaraj P. Modelling the impact of different intervention packages for malaria control under varying intensities of pyrethroid resistance. Malar J Malar J. 2025;24:411.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinda PG, Eichenberger C, Ngowo HS, Msaky DS, Abbasi S, Kihonda J, et al. Comparative assessment of insecticide resistance phenotypes in two major malaria vectors, \u003cem\u003eAnopheles funestus\u003c/em\u003e and \u003cem\u003eAnopheles arabiensis\u003c/em\u003e in south-eastern Tanzania. Malar J. 2020;19:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8439202/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8439202/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMalaria control gains are stagnating or reversing, in part due to widespread insecticide and drug resistance, as well as increasing financial and implementation challenges. This study assessed the national strategies for insecticide resistance monitoring and management in Tanzania to identify key barriers and misalignments between policy and actual practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe initially reviewed technical documents from Tanzania’s National Malaria Control Programme (NMCP) produced between 2014 and 2024, along with World Health Organization (WHO) guidelines and reports on insecticide resistance monitoring and management. This was followed by in-depth interviews with key informants in Tanzania, including policymakers, representatives from funding agencies, technical experts, scientists, and vector control implementers at district and regional levels. The qualitative data was analyzed thematically using NVivo software.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe document review revealed strong policy alignments of the NMCP strategies for monitoring and management of insecticide resistance with international practice as recommended by WHO. However, implementation of the policy intentions remained limited, with resistance monitoring being conducted in only 22 of Tanzania’s 184 district councils. Interviews with 24 stakeholders highlighted significant gaps between the stated policies and guidelines and the actual practice. These gaps were driven by inadequate financing, donor dependence, insufficient coordination and dissemination of guidelines, limited technical capacity, and weak engagement of communities and district-level operators. Participants emphasized that without strengthened surveillance systems, sustainable local financing, and greater community and intersectoral collaboration, achieving the current strategic goal of malaria elimination by 2030 remains unlikely.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite strong policy alignment and strategic planning, Tanzania's implementation of insecticide resistance management remains limited. Bridging these persistent policy-practice gaps is essential for more effective malaria vector control, and will require sustained financing, strengthened coordination, improved vector monitoring, and enhanced community and intersectoral engagement.\u003c/p\u003e","manuscriptTitle":"Policy-practice gaps and barriers to the effective management of insecticide resistance in Tanzania","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 09:44:49","doi":"10.21203/rs.3.rs-8439202/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"144904143833367009783799978069658636842","date":"2026-02-15T15:34:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-27T14:34:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-28T14:47:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-24T17:49:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Malaria Journal","date":"2025-12-24T05:35:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c812da1e-9607-4124-87f1-d08d1174f3f5","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-29T09:44:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 09:44:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8439202","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8439202","identity":"rs-8439202","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}