**13. Using IVM for optimal IRM implementation**

**12. Policy implications of insecticide resistance**

170 Insecticides Resistance

depending on local research projects being conducted [7].

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,

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

Given the backdrop of escalating resistance and limited vector control tools, as well as global finances that continue to fall short of estimated requirements for malaria control and elimina‐ tion [2] and restricted entomological capacity [190], there has been some progress in the implementation of the GPIRM [191]. A successful IVM programme includes actions along five key strategic elements that can be harnessed for addressing the pillars of the GPIRM pertinent to country-level strategic planning and implementation. First, Advocacy, social mobilisation, and legislation: to strengthen national insecticide legislation and regulatory mechanisms for their safe and judicious use; ensure insecticide resistance advocacy and communications to effectively target policy makers, implementers, communities, and other stakeholders. Second, Collaboration within the health sector and partners: to establish technical support linkages with insecticide manufacturers and distributors for joint entomological monitoring, insecticide selection, and resistance management; establish partnerships with the ministry of agriculture and ministry of environment for supervision and pesticide management. Third, Capacity building: to identify competencies and staffing levels essential for effective IRM; strengthen human resource capacity through training for entomological resistance monitoring; establish requisite infrastructure including insectaries, entomology labs; establish vector control data management systems. Fourth, Evidence-based decision-making: clarify information needs and data collection methods; establish entomological and epidemiological monitoring plans to help target and evaluate interventions; select insecticides based on local data regarding vector susceptibility and transmission ecology, ensure insecticide selection is based on an IRM plan as outlined in the GPIRM; ensure vector control and vector data collection are completed in a timely and rigorous manner; manage and utilise evidence for decisions and strategy refine‐ ment, including annual reassessment. Fifth, Integrated approach: ensure there is adequate, evidence-based guidance on the impact of resistance on malaria vector control interventions; evaluate whether agricultural use and other vector-borne diseases have an impact on resist‐ ance; explore additional non-insecticide complementary malaria vector control measures where they may be appropriate [3, 4].
