In Madagascar’s Remote Villages, Women Do the Work of Doctors Without Recognition or Pay

A mother from the remote village of Andasifahadimy holds her child’s vaccination records on July 7, 2025. CHWs have visited her community to immunize children and record each dose in this booklet. Credit: Trisha Mukherjee for More to Her Story

ANTANANARIVO, Madagascar — For 23 years, Brigitte Razafitsalama has trekked over steep roads, under pouring rain, and amid sweltering heat to provide healthcare to rural families in Madagascar. An animated woman with closely-cropped hair, Razafitsalama’s enthusiasm for her role as a community health worker (CHW) in the outskirts of Antananarivo, Madagascar’s capital, is indefatigable: “I was born with the desire to help people,” she told More to Her Story.

Razafitsalama, a grandmother of seven, is one of two volunteers who fulfill a role similar to a primary care physician for over 200 families, many of whom cannot otherwise access basic healthcare. In addition to volunteering 20 hours a week, she works as a teacher and cook. While her role as a CHW is part of an official partnership with the government of Madagascar, Razafitsalama is not paid for her time and labor, often using her savings for transportation and materials. 

“No one else will do this job, because there’s no money,” she said. “That’s why my hair is gray, and I’m still here.”

Razafitsalama loves her job, and the community she serves loves her back. As she walks down the cobblestone roads covered with a film of red dust, people call out to her, asking for advice about their pregnancies or their babies’ food habits. Sometimes they run up when they see her to ask for vaccines and supplements. Despite only having a high school education, many call her “doctor.”

“Everyone knows us,” she said matter-of-factly. “We are famous here.”

Brigitte Razafitsalama stands in her clinic in the outskirts of Antananarivo, Madagascar on June 27, 2025. Credit: Trisha Mukherjee for More to Her Story

On a Friday morning, Chantal Rahelinirina cradled her sleeping two-week-old baby under the soft light of  the one-room clinic Razafitsalama uses as a base. A baby scale lay in a corner; just beyond it, chipped paint on the walls peeked out behind hand-made velcro cut-outs of fruits and vegetables that Razafitsalama used to teach local illiterate mothers about nutrition. Underneath a table stacked with fresh carrots and cabbage, Razafitsalama drags out a metal canister of gasoline for the stove she uses for nutrition-focused cooking demonstrations. She buys the fuel with her own savings, she said.

The effort pays off. Rahelinirina, for one, has benefitted from the nutrition advice. While she and her family used to consume only coffee, rice and the occasional green vegetable, she learned from Razafitsalama to eat at least five different foods a day. Now, she and her children feel stronger and healthier, she told More to Her Story. 

In a region with significant rates of acute malnutrition, Razafitsalama’s dedication has upheld an entire community: In January, six children in her town developed malnutrition. But after Razafitsalama instructed their families about optimal breastfeeding, nutrition, and supplements, five of those children made full recoveries.

“I do not want to see my community suffering,” she said.

In Madagascar, 30 to 40 percent of people have no access to any form of primary healthcare, and many who do have to walk over 10 km to reach a clinic. So instead, Razafitsalama brings the clinic to them, visiting her patients door to door.

Across the world – particularly in developing countries – CHWs receive training from the government and international nonprofits to fill crucial gaps where traditional medical infrastructure falls short. Almost 70 percent of global CHWs are women, who are often more skilled at building rapport and trust to deliver cost-effective services, including vaccinations, emergency nutrition supplements, Vitamin A, family planning, and preventive care. And their help has saved lives: In Ethiopia, CHWs reduced child mortality by half. In Nepal, they contributed to a 50 percent reduction in maternal mortality rates. In Burkina Faso, CHWs helped triage an onslaught of terrorist attacks beginning in 2015, increasing vaccination rates despite the violence. 

“They are absolutely foundational to make health services work,” said Shawn Baker, Chief Program Officer of Helen Keller Intl, which works to improve healthcare access in partnership with community health workers.

Yet, despite the fact that CHWs provide lifesaving services around the world, the vast majority of them – 86 percent – are not given a salary for their work.

“I do think that probably one of the single biggest mistakes we've made in public health is always treating them just as volunteers,” said Baker.

Melphine Raoliarimalala and Hanitriniaina Olivia Ranaivoson, CHWs in Ambositra, conduct a home visit on July 4, 2025. Credit: Trisha Mukherjee for More to Her Story

Several hours south of Madagascar’s capital, in Ambositra, Melphine Raoliarimalala and Hanitriniaina Olivia Ranaivoson take time off from their jobs to spend their Friday morning visiting over a dozen homes to ensure each child is up to date on vaccinations. The two CHWs yell to hear each other over the wood-cutting machinery at one home and shoo away chickens in the yard of another. Each family thanks them sincerely for vaccinating their children. One middle-aged man asks them, “Can you help me get a vaccine too?”

Although Raoliarimalala and Ranaivoson are volunteers, they would appreciate some financial support –  $2 each for a morning’s work would be sufficient, they posited. Per year, this would earn them a little more than half of the average annual income in Madagascar.

A four hour drive east from the capital, near the mist-veiled rainforest village of Andasifahadimy, another group of community health workers gingerly climbed atop a bundle of sticks generously labeled a raft. Their goal was to cross a river to vaccinate children on the other side – children who otherwise would rarely, if ever, receive any healthcare. As they paddled their way across the rushing white water, the raft barely stayed above the surface. “They were really scared to take it across the river because most of them cannot swim,” said Justorien Rambeloniaina, a conservation scientist who accompanied the CHWs. 

But the trip was worth it. That day the CHWs administered vaccines, treated two cases of severe malnutrition, and brought a six-year-old girl with malaria to the hospital, potentially saving her life.

A mother in Andasifahadimy has walked over three hours alone with her children to visit the nearest clinic on July 7, 2025. CHWs save mothers like her the long and sometimes dangerous journey. Credit: Trisha Mukherjee for More to Her Story

Many families across the country interviewed by More to Her Story believed that CHWs deserve remuneration and support. Richard Ramilison, who lives in an isolated stretch of Madagascar’s central highlands, said his family and their neighbors each contribute a bag of rice to their two CHWs. “They work really hard,” said Ramilison, adding that the gifts of rice aren’t nearly enough for the work the CHWs do. “The only thing missing is the funding.”

But when it comes to paying Madagascar’s CHWs, Secretary General of Health Lethicia Lydia Yasmine lamented: “not yet.” Supplying a salary for each of the country’s 50,000 CHWs would be impossible to afford, she claimed. “We simply don’t have the money.”

Yet, reports of corruption and wasteful spending are common in Madagascar. Residents noted with frustration the cable cars that hover, unmoving, above Antananarivo’s highways These cable cars cost 152 million euros to construct but are still not functional despite being inaugurated about a year and a half ago. Moreover, the cost per ride – about $1.15 – is beyond reach for the majority of the population, who earn less than a dollar a day. 

In contrast, the budget for the cable car project could pay all of Madagascar’s 50,000 CHWs for decades of work.

Experts suggest paying CHWs would be one of the best investments developing countries like Madagascar could make. One study conducted in 2015 by the World Bank Group, the Clinton Foundation, and UNICEF, among other organizations, found that investing in CHWs in sub-Saharan Africa would bring an economic return of up to 10:1 due to increased productivity from a healthier population and reduced risk of epidemics, among other factors. At the same time, if and when countries remunerate CHWs, advocates say it’s important to ensure the women who have been serving their communities do not get cast aside by men – or elected officials’ personal connections – taking their jobs for the financial promise.

In any case, it would be hard to replace CHWs like Razafitsalama. It is impossible to calculate the exact number of lives they’ve changed or saved, but their communities see them as superheroes who provide invaluable care and protection. Many of these communities want the government – and the rest of the world – to value CHWs just as much as they do. 

Although Razafitsalama is in her 60s, she never wants to stop being a CHW — but she also doesn’t want to be taken for granted for the rest of her life. 

“We need some more support,” she said. “It’s only fair.”