**12. Policy implications of insecticide resistance**

To maintain the effectiveness of vector control, countries are encouraged to deploy tools within the context of IVM [3] and to pre-emptively implement suitable IRM strategies against malaria vectors [7]. To help control programmes re-orient to IVM and IRM, strategic direction and technical assistance have been provided for the two approaches. WHO guidance on IVM includes: the Global Strategic Framework for IVM (2004) [3], the Report of the WHO Consul‐ tation on Development of a Global Action Plan for IVM [4], Guidance on Policy Making for IVM [185], Core Structure for Training Curricula on IVM [186], Handbook for IVM [187], and Monitoring and Evaluation Indicators for IVM [188]. Yet, only 62% of 113 endemic countries globally and 53% of countries in Africa have national IVM policies and implemented the strategy [184]. Moreover, resistance to at least one insecticide has been identified in 64 countries with on-going malaria transmission [7]. The threat posed by insecticide resistance is high‐ lighted in the GPIRM consisting of five key pillars including: 1) planning and implementation of IRM strategies in malaria-endemic countries; 2) ascertaining proper, timely entomological and resistance monitoring coupled with effective data management; 3) the development of new, innovative vector control tools; 4) filling of gaps in knowledge on mechanisms of insecticide resistance and the impact of current IRM approaches; and 5) making available enabling mechanisms such as advocacy and human and financial resources [7]. The current monitoring of insecticide resistance is inadequate and inconsistent in most settings in which vector control interventions are used. Often, monitoring is performed reactively or ad hoc, depending on local research projects being conducted [7].

With the view to operationalise the GPIRM and optimise resistance monitoring and manage‐ ment, the WHO has developed a framework document for countries to use as a template for their insecticide resistance monitoring and management plans [189]. However, very few countries have established rational IRM strategies and incorporated them into operational IVM-based vector control programmes. Notably, an emergency approach needs to be adopted for IRM with continued advocacy for the GPIRM, similar to that given to Artemisinin resistance management plans is essential. Incorporating other vector-borne disease (i.e., dengue, leishmaniasis, etc.) in the GPIRM and emphasising biological agents, housing improvement, and larviciding as IRM tools is crucial. For example, larviciding uses differ‐ ent classes of chemical insecticides and biological agents with different modes of action to the four classes available for adult vector control and can reduce overall density [184]. The current areas of focus within IVM include: redesigning programs in the context of insecti‐ cide resistance response and climate change; reorientation of programs with capacity building and career pathways; encouraging intersectoral work; and IVM in emergency situations [184]. The WHO should address resistance and entomological capacity challenges via support to countries for developing IRM plans, the inclusion of additional mechanism data in the global database, bi-regional training, the development of a global insecticide resistance response plan, and advocacy for action and resource mobilisation. In attempting to control and contain the spread of insecticide resistance, multi-country cross-border reporting systems and proactive planning is also crucial to preserve new tools and should be considered to inform policy at this level, especially in light of the malaria elimination efforts that many countries have embarked upon [168].
