Barriers and facilitators to the adoption of multiple first-line therapies for management of uncomplicated malaria in Tanzania: a multi-method qualitative study.

BACKGROUND: Malaria remains a major public health burden in Tanzania, where Plasmodium falciparum accounts for 96% of infections and children under five years experience the highest mortality. The emergence of kelch13 mutations and partial resistance to artemisinin derivatives poses a threat to the sustainability of artemisinin-based combination therapy (ACT). Reliance on artemether-lumefantrine (ALU) as the dominant first-line treatment increases selective pressure. The World Health Organization recommends multiple first-line therapies (MFT) to slow the development of resistance. This study examined the barriers, facilitators, and potential strategies for adopting MFT for uncomplicated malaria in Tanzania. METHODS: A multi-method qualitative study was conducted. A desk review of national malaria data (2020-2024) was conducted to examine trends in incidence, mortality, and treatment outcomes. Data on importation from the national medicine regulatory authority (2021-2025) were analysed to assess the ACT importation pattern. The desk review provided epidemiological and pharmaceutical context for qualitative enquiry. Semi-structured interviews were conducted with purposively selected participants, including policymakers, regulators, supply chain managers, and frontline healthcare providers. Interviews were transcribed and thematically analysed using Braun and Clarke's framework with NVivo software. RESULTS: From the NMCP desk review data between 2020 and 2024, malaria cases declined from approximately 8.9 million to 7.2 million before resurging to 8.1 million in 2023; deaths followed a similar trend. Children under five consistently bore a higher burden, representing 34% of all cases and 46% of deaths. While case incidence in this age group declined significantly (p = 0.011), mortality showed no improvement (p = 0.802). Importation data revealed ALU comprised 73.5% of all antimalarial imports, compared to 12% for artesunate, 6% for artemether, and only 2.6% for dihydroartemisinin-piperaquine, highlighting limited diversification. A total of 12 Qualitative interviews identified barriers, including the high cost of alternative artemisinin-based combinations, limited provider training, and weak supply chains. Facilitators, on the other hand, demonstrated a strong political commitment, engaged in capacity-building initiatives, and relied on therapeutic efficacy and pharmacovigilance data to inform their approach. CONCLUSION: MFT presents a promising strategy for prolonging ACT efficacy and enhancing malaria case management in Tanzania. However, financial constraints, import dependence on ALU, and inadequate provider preparedness limit implementation. Successful adoption will require diversification of ACT imports, strengthening supply chains, sustained capacity-building, and embedding surveillance and regulatory data into policy decision-making.