Southern African officials have called on Madagascar to urgently hold elections, after yet another plan to restore constitutional order collapsed. The Indian Ocean country has been embroiled in a political crisis since 2009, when the mayor of the capital overthrew the president.

In 2009, the Southern African nation of Madagascar was known as a remote island paradise, renowned for its biodiversity, its vanilla crops, and its stunning beaches.

But a coup that year, led by the mayor of the capital, pushed the Indian Ocean island into chaos. Today, as the coup leader refuses to step aside and allow elections, the nation is deep in political turmoil that a top humanitarian official described as a "silent crisis."

UNICEF representative to Madagascar Steven Lauwerier said the island's 22 million people are suffering as coup leader Andry Rajoelina continues to ignore calls to take his name off an upcoming ballot.

"Most of the development indicators have deteriorated or have stagnated. While we have seen in most other African countries they improved," he said. "In Madagascar things went worse than they were before."

Lauwerier says nine out of 10 Madagascar residents live on less than $2 a day. More than 1.5 million children are out of school. Half of children under five years old are chronically malnourished, which leads to irreversible damage. Hundreds of health centers have closed. And whereas the nation was on track to reach the U.N. Millennium Development Goals by 2015, those are now unreachable.

That decline, he says, can be directly attributed to the political crisis. Since 2009, government spending and donor aid have declined because of the political situation.

Rajoelina's refusal to come off the ballot also means that there will be no vote, yet again.

Regional negotiators have for years tried to find a solution that will bring in elections and a peaceful transition. The vote has already been postponed numerous times and now is tentatively set for late August.

Madagascar cannot afford to run its own election without international support, and major blocs like the African Union and the Southern African Development Community say they will withhold that support until Rajoelina complies.

If the impasse continues, said analyst David Zounmenou of the Pretoria-based Institute for Security Studies, sanctions could further marginalize Rajoelina. The economy has taken a dip during his tenure, said Zoumenou, with 200,000 people losing their jobs.

"The other factor that I think is very important is what is already appearing: the cracks within the army and the discontent, the popular discontent, among the citizens," he said. "The same way he came to power, through popular uprising, is going to be the same way he [leaves] power, through popular uprising. Because people are losing their jobs, youngsters who cannot get employment will simply point at him as the man responsible for the situation that is prevailing in Madagascar ... And with what is happening across the continent between northern Africa, young people are inspired. They are no longer willing to accept leaders who impose themselves on the citizens."

Former president Didier Ratsiraka and the wife of exiled ex-president Marc Ravalomanana were allowed to join the ballot, so Rajoelina did too.

Zounmenou said none of the three should have even been allowed to run. Ratsiraka and Ravalomanana because they have not met residency requirements, and Rajoelina because he agreed not to run as part of a SADC negotiated deal.

Aid officials do not care who is elected to the presidential palace, as long as the impasse is broken and humanitarian work can resume, said Lauwerier.

"First of all, the stalemate has to come to an end, and I think the politicians in this country should try to find a solution, whatever it takes to find that solution, as the political crisis has actually led to this dire situation," he said.

Whether that will happen is up to one man, and he does not appear to be going anywhere.

[This report was amended by VOA after first publication - AllAfrica editors.]