LONDON, United Kingdom — Mental health in Madagascar has long been absent from public discourse, overshadowed by entrenched stigma, endemic poverty and an underfunded health care system. Yet, recent years have shed light both on the extent of the mental health crisis and on a few avenues of progress, primarily driven by Malagasy organizations and committed scholars.
Mental Health and Poverty
Despite a population exceeding 30 million inhabitants, Madagascar counts just 14 practicing psychiatrists, fewer than one per million. This figure is 250 times below what the WHO recommends, with most specialists and specialized facilities located in the capital, Antananarivo.
The number of psychiatric nurses is severely limited and the number of psychologists does not exceed fifty. With only five psychiatric hospitals and 11 psychiatric units concentrated in the capital and urban centres, rural populations, 60% of the Malagasy demographic, are compelled to travel hundreds of kilometres to access treatment.
The mental health crisis in Madagascar is inseparable from the country‘s socioeconomic and environmental hardships. More than 80% of the Malagasy live below the poverty line. The country ranks among the highest on the Global Hunger Index, with 36.3% and stunting rates remain high.
Climate instability intensifies these pressures, with southern Madagascar the area most strongly affected, experiencing a climate-induced famine in 2021. Droughts, cyclones and extreme heat have turned fertile land into arid desert, resulting in food and water scarcity. Adolescents are the ones who bear the heaviest psychological toll from hunger, witnessing starvation and losing educational access. The U.N. has documented a clear rise in mental health disorders tied to the humanitarian crises in the south of Madagascar.
Training Gaps and Medicine Shortages
General practitioners, the leading rural providers, often lack psychiatric training. Dr. Mioramalala, an expert at the National Center for the Application of Pharmaceutical Research (CNARP), notes: “University training in mental health remains distant, sometimes quickly forgotten once the practitioners are working in the field. Clinical practice focuses more on communicable or noncommunicable diseases, such as hypertension, diabetes or respiratory infections.” Due to fear or lack of confidence and training, some general practitioners are also reluctant to diagnose and treat mental health disorders.
Medicine shortages compound the challenge. Public pharmacies only stock anxiolytics, while antidepressants, antipsychotics and mood stabilizers can only be found in private pharmacies. Families must therefore choose between basic needs and treatment, as there is limited insurance coverage for psychiatric care. Newer antidepressants and dopaminergic treatments remain largely absent altogether, leaving treatment-resistant patients with limited solutions.
The Weight of Stigma
As Mioramalala explains, mental health conditions remain misunderstood, often interpreted through sociocultural beliefs, rooted in Madagascar’s 18 ethnic groups and diverse religious landscape. It is a commonly held belief that mental illness is the result of witchcraft or possession. As a result, most patients present at psychiatric hospitals only after consulting a traditional healer or undergoing a so-called “religious delivery” and only if their condition has not improved.
Many will never consult because of shame. According to Dr. Nambinina Rasolofotsialonina, just one in five patients with conditions such as schizophrenia or bipolar disorder accepts their diagnosis and treatment.
Intervention Lessons
Despite these challenges, recent interventions show that change is possible. Between 2013 and 2018, Madagascar’s Ministry of Public Health piloted a substantial program in five regions. It trained 102 general practitioners (GPs) and funded 44 university mental health diplomas while conducting public awareness campaigns.
Results were encouraging but mixed. Consultations doubled in intervention areas (4.5% vs 2.3%). Trained GPs displayed stronger knowledge, particularly for schizophrenia and epilepsy. Key medication availability improved significantly in the intervention areas.
However, diagnostic accuracy remained low, as GPs agreed with psychiatrists on mental health diagnoses in fewer than one in five cases, although intervention areas performed better (28.6% vs 11.1%). Public awareness rose modestly for epilepsy, but barely moved for depression and schizophrenia. However, it proved that consistent training and investment could deliver measurable improvement in access, practice and supply.
NGO Initiatives
Malagasy NGOs are also pioneering solutions and filling gaps in mental health provision:
Water Yourself is one of the few organizations offering mental health services and education, such as diagnosis, prevention, therapy, workshops and counselling. Since 2021, it has partnered with 15 businesses and five NGOs, helped more than 1,000 individuals and achieved a 10% awareness increase. Its integrated approach blends therapy, advocacy and community empowerment.
Psy-Kôzy Madagascar, launched in 2021, is another initiative that substantially reduces stigma and encourages psychiatric rehabilitation. By collaborating with Humanity & Inclusion (HI) and the hospital center, Le Vinatier, in France, it has strengthened efforts to support mental health in Madagascar. In 2023, it also co-hosted an international conference on mental health recovery, helping amplify Malagasy voices, challenge misconceptions about mental illness and empower individuals with lived experience.
HI demonstrates innovative integration, linking mental health with maternal care, disability prevention and climate resilience. Its HIFALI project in the Boeny region strengthens community-based responses, while its work in prisons and with malnourished children shows the connection between mental health and broader survival needs.
Priorities for Progress
As outlined by Mioramalala, there are currently three urgent priorities. First, nationwide public campaigns must be implemented to provide accurate information and help people seek help as early as possible.
Second, general practitioners must be trained to treat mental health conditions, such as anxiety, depression, addiction, bipolar disorder, schizophrenia and psychosis. “Training should be ongoing, with refresher courses and follow-up training to support practitioners in their daily work,” argues Mioramalala.
Finally, the availability and access of psychotropic drugs must expand significantly, with “affordable prices guaranteed for the entire population,” stresses Mioramalala. This step is critical if patients are to avoid choosing between essential treatment and basic survival needs. While NGOs can help fill gaps, sustained government funding remains vital.
From Silence to Voice
Younger generations are also beginning to show greater awareness and mental health in Madagascar is slowly gaining traction. State interventions, though limited, show that targeted approaches can slowly but surely improve things. NGOs and initiatives are creating inclusive, community-rooted care models that achieve impressive reach with limited resources.
The path forward is well captured by the Malagasy proverb “tsy misy manana ny ampy fa sambatra izay mifanampy,” which means that no one has enough, but blessed are those who help each other. The future depends on policymakers, psychiatrists and general practitioners, neighbors, teachers, healers and community leaders willing to talk, listen and care.
– Juliette Delbarre
Juliette Delbarre is based in London, United Kingdom and focuses on Global Health, Politics for The Borgen Project.
Photo: Flickr