Against the odds: Madagascar’s fragile polio victory

Antranolahatra, MADAGASCAR — It had the vibes of a small town raffle night. Music blasted from a loudspeaker, and a woman stood at the front of the crowd with a microphone, calling out names, ushering them forward.

Children who were old enough danced — bobbed their knees, swayed side to side, and tapped their little toes. They cartwheeled, sang, braided each other’s hair, and dared each other to jump across a sand pit — giggling uncontrollably.

As the day wore on, some started causing mischief and were quickly scolded by adults with wagging fingers.

For these children, it was an epic party, but for the youngest, it was hardly so.

It was vaccination day for the remote village of Antranolahatra in southwest Madagascar, with a makeshift clinic hosted under the shade of two trees, surrounded by a cactus fence.

Mothers came forward with swaddled babies who wailed in their arms — thrashing to avoid the barrage of needles jabbed in multiple limbs. Older siblings were tasked with holding babies down, but for particularly squirmy ones, several adults joined in.

The mothers rocked and wiped away their babies’ tears — while also laughing at the dramatic displays.

This is all part of Madagascar’s effort to protect its children from vaccine-preventable diseases, including polio — a disease that paralyzes and kills.

It’s an incurable disease the international community has invested heavily in eliminating, although there are still flare-ups and spots of stubborn persistence.

Local officials, such as chiefs and religious leaders, were tasked with getting communities on board, alongside community health volunteers. Posters were plastered around towns, and radio announcements blasted.

Mamiarisoa Vola Adrienne Josia and Ravaonindrina Antoinette were two community health volunteers on these campaigns.

They first went house to house, identifying children under 5 and convincing parents of the necessity.

During the campaign, they returned with a health worker and someone to register the vaccination.

During polio campaigns, teams are deployed nationwide for about five days. 

 The country was able to improve the effectiveness of campaigns, and successes have been credited to intensified surveillance, robust community engagement, and political will — for example, the nation’s president and first lady are strong vaccine advocates. 

The government inaugurated a vaccine warehouse — the largest of its kind in Africa. President Rajoelina declared last year the “year of immunization,” and first lady Mialy Rajoelina became a vocal immunization champion. 

“People listen to that type of messaging,” Gavi’s Clark said. “It wasn’t just a handshake meeting; they were really hardcore. … It wasn’t just words.”

UNICEF also appointed a young social media influencer to champion the fight against polio. 

A Gates Foundation grant supports UNICEF in promoting government engagement on fighting polio and encouraging other vaccinations.

Now, the country is on alert: Posters plastered on health facility walls tell health workers to raise alarm and take stool samples if someone is paralyzed, and a new “state-of-the-art” laboratory to detect the virus, hosted at the Institut Pasteur de Madagascar, was recently transferred to the government. 

From 2019 to 2023, more than a million Malagasy children under 5 years old were estimated to be without any vaccinations, but that’s been reduced by about 39.5%, according to the Ministry of Health. 

But she’s fine with vaccinating her 1-month-old grandson at her neighborhood facility. She recently brought him to a routine vaccination day.

Some families also found the quantity of polio campaigns unsettling — growing suspicious of the necessity of having seven rounds.

Now, since there hasn’t been an identified polio case in over a year, the strategy has changed.

The country is largely dependent on routine vaccination — a combination of relying on children brought to health facilities and outreach to remote communities where it’s difficult for families to access clinics. The government also organizes, with partners, nationwide campaigns offering an array of vaccines. 

Vaccination day under the trees in Antranolahatra village was an example of that type of outreach.

A married couple who work as community health volunteers laid the groundwork.

The wife, Marie Laurence Tsirakofa, has been a community health volunteer for 22 years. Her husband, Koto Jean, left his role as village chief in 2010 to join her. 

In the lead-up to vaccination day, they traveled around their community identifying kids needing vaccines and handing out referral slips.

At the beginning of vaccination day, they gathered over 70 children’s vaccine booklets and called them in turn. Jean sat with his glasses at the tip of his nose, furiously cross-checking vaccination books against their own records.  

Doctors for Madagascar, an international nongovernmental organization, supported this vaccination day as part of work funded by Gavi, Bayer Foundation, and UBS Optimus Foundation.

Many kids received their first polio vaccine that day. This included 7-month-old Dauphine, whose mother had been farming in a distant field during the last polio campaign and missed the initial opportunity.

The winding roads of Ifanadiana district in the eastern region of Madagascar — about a day's drive from Antranolahatra village — cut through rolling mountains dappled with eucalyptus trees and terraced rice fields.

Mothers tend to walk with babies in one arm and baskets on their heads. Vendors will sell black strips of vanilla and deep-fried bananas. Small herds of zebu — or humped, horned cattle — are shepherded amid bustling markets.

The air is usually filled with wafts of flowers and echoes of babbling brooks. 

The landscape is equally breathtaking, as it is a logistical nightmare.

Vaccines are distributed to districts, but must then be delivered to health facilities. Some are nestled far away from main roads that require crossing a river and mountainous terrain to reach. 

Pivot, a Malagasy NGO, is one of the organizations assisting the government in getting vaccines to remote facilities in a few districts.

It can take three days to reach the furthest health facility in the Ifanadiana district — just one way — with the round trip taking about six days.

Reaching the most distant facilities is a major challenge.

As two of Pivot's motorcycle drivers, Rakotonirina Malala Dieu Donné and Randrianarison Blaise Mahmias, explained, they can only get so far on their bikes before the terrain becomes too rough to continue.

And so they meet someone from the health facility who may have walked a day to meet them. That person must then travel another day, with a cold box slung over their shoulder, to bring the vaccines to the health facility.

Once at the health facility, vaccines need refrigeration.

About 75% of basic health facilities in Madagascar lack electricity or only have a solar refrigerator. Some refrigerators are out of service, with maintenance challenges.

This means health facilities can’t stock up. 

And cyclones complicate this further. With floods, even motorcycles can’t pass roads — and sometimes the drivers must negotiate with farmers to dig tunnels to divert water. 

Hundreds of miles away at the two-room Bemanga health facility in southwestern Madagascar, there’s no internet, electricity, or bathroom, and there's limited cellphone service.

It’s about three hours from the nearest city, and to reach it, you must go off-road for about an hour on a bumpy path with ravines and terrain that shapeshifts from sand to soil.

The clinic serves over 4,200 people.

Zapolino Sylvana Razanantsoa, a nurse, was sitting on the observation room bed one day when a message popped up on her phone.

She realized that was one of the few places her phone had service. She nailed a plastic brace on a wooden window and now must stand on the bed, leaning her head against the window to receive calls.

That’s how she receives vaccines. She knows she will receive a call on certain days saying vaccines will fall from the sky, landing in a nearby field in about half an hour.

It’s a drone project, which started last October in three regions, funded by Gavi and implemented by PSI Madagascar, in partnership with the government. 

And while it’s not perfect — sometimes vaccines break upon landing — it’s more reliable than when they previously waited for land deliveries. 

Dr. Razanakolona Herimaminiaina Robert, the medical inspector for Sakaraha district, said that the majority of his district's health facilities use drones for vaccine delivery, particularly those located over 30 miles from Sakaraha town.

He said reaching children “perdu d’vue,” or “lost from view” in French, is one of the health ministry’s greatest challenges.

For his district, there’s a particular problem with nomadic communities artisanally mining sapphires. When the gem reserves are depleted, they pick up their lives, moving to other gemstone deposits.

The district currently uses mobile clinics to reach isolated and nomadic populations, but it needs more of them to meet the demand. But they are expensive, Dr. Robert said, with costs such as fuel.

Ravelomahafaly Herimaminiaina Christian, a technical adviser at Doctors for Madagascar, said he knows of a community living over 85 miles from a health facility.

“Especially if it’s from foreigners; they can’t do good things like this for free.”

There’ve been a few times where parents say to her, “If my child dies tonight, I’m going to come for you.” In response, she dropped the polio vaccine into her own mouth to prove safety.

Another community health volunteer, Yvonne Crystelle, said about one-third of the children she assessed through her work with Doctors for Madagascar hadn’t yet been vaccinated for polio.

One focus was improving data — digitizing it and making it accessible to decision-makers. Community health volunteers were provided reimbursements for the distance traveled and accommodation to come to meetings where data was consolidated, including on vaccinations.

This phase of the program was winding down this year, but the Trump administration’s dismantling of USAID brought the remaining work to a halt in January.

Before Trump took office, there were expectations the work would continue — there’d been a call for proposals for the program’s next iteration.

A health facility chief said that since the program ended, the number of patients referred to her clinic has decreased, and so has data quality.

Some health volunteers are no longer spending time visiting villages and coming for monthly meetings to cross-check data because they no longer receive cost reimbursements.

Other terminated USAID Madagascar programs could also stem efforts to keep polio at bay, such as a $35 million project launched last year to improve clean water access and sanitation in rural areas; a $10 million sanitation project in urban areas; and a $1.3 million WHO grant aimed at supporting health systems, strengthening mental health services, and enhancing disease outbreak response.

Beyond USAID, the U.S. told Gavi it’s cutting its support. The country also announced its withdrawal from WHO and has proposed UNICEF funding cuts.

The GPEI said U.S. funding cuts haven’t materially affected their own budget this year, and the U.S. budget process is ongoing, but they are expecting a decision on future polio funding from the U.S. in the coming months.

The biggest immediate gaps have been with the U.S. CDC’s activities, particularly surveillance. Countries across Africa have had to reduce the frequency of collecting samples from the environment to test for the poliovirus and halt expansions in high-risk areas, according to the initiative.

“Overall, the GPEI is preparing for significant cuts from some of its biggest donors that will force the program to make tough decisions very soon,” the initiative told Devex.

“Ultimately, achieving and sustaining polio eradication is only possible when all health partners (civil society organizations, essential immunization programs) have the resources they need to ensure every child is protected through vaccines,” GPEI said.

But despite diminished resources, there have been global calls for sustained prioritization of vaccines, as one of the most cost-effective public health interventions. According to UNICEF, one vial of oral polio vaccine costs $2.82 and contains 20 doses.

“The idea of a child dying or being paralyzed by a vaccine-preventable disease is just tragic,” Gavi’s Clark said.

“It’s the responsibility of the world to take care of its children,” she added.