Beyond national household surveys: routine and alternative approaches to sustain robust evidence-based decision...

Robust, timely, and decision-oriented surveillance, monitoring, and evaluation (SM&E) systems are fundamental to malaria control and elimination. National household surveys such as the Demographic and Health Surveys (DHS), Malaria Indicator Surveys (MIS), and Multiple Indicator Cluster Surveys (MICS) have historically provided high quality, comparable estimates of malaria burden and intervention coverage. However, substantial recent reductions in global malaria financing have led many endemic countries to delay, scale back, or cancel these surveys, resulting in widening evidence gaps. This perspective paper discusses how malaria programs can adapt by employing a broader set of SM&E approaches. We summarized the use-cases and key considerations of several alternative methodologies, including routine health facility surveillance, first antenatal care visit (ANC1) surveillance, sentinel surveillance systems, Lot Quality Assurance Sampling (LQAS), and targeted cross-sectional surveys, and described how these approaches can reduce reliance on large-scale surveys. While each method has its strengths and limitations, their usefulness depends on the primary SM&E objective, as well as assessing feasibility and data quality, and accounting for transmission setting and representativeness. Routine surveillance remains the central platform for malaria SM&E and should be strengthened to provide quality, continuous, geographically granular insights. Alternative methodologies can add value by validating trends, capturing asymptomatic or non-care seeking infections, or enabling rapid classification against program thresholds where timely decisions are required. To support transparent and context-appropriate method selection, a multidisciplinary taskforce under the Roll Back Malaria Partnership's (RBM) SM&E Working Group developed the SM&E Decision-Support Tool. This tool translates expert consensus and a targeted evidence review into a practical decision tree that aligns methodological options with stated objectives, data availability, and implementation context. It is designed to guide SM&E planning discussions rather than replace feasibility assessments. In conclusion, malaria programs should invest in strengthening routine surveillance systems while adopting a broader, fit-for-purpose portfolio of complementary methodologies tailored to specific decision needs. Further comparative work on costs, feasibility, data quality, and precision levels across settings is needed. Building a stronger evidence base for method selection will help ensure that SM&E strategies remain transparent, appropriate, and sustainable under resource constraints.