Obstetrics and Gynecology International Health service research studies have identiﬁed that another means of ensuring sustainability of programmes is through decentralization of laboratory services, such as provision of same day testing and treatment through rapid point-of-care tests [17, 20–23]. Several such tests that are heat stable, easy to use, and low cost ($0.19–0.99 per test) have been found to be sensitive and speciﬁc in very basic clinic settings [21, 22]. Use of such point-of-care tests ensures women with positive results are treated as early as possible, minimizing loss to followup and maximizing the potential to avert pregnancy complications. Currently available point- of-care syphilis tests are all treponemal tests, identifying any prior infection (even previously treated cases) as opposed to active infection. This can result in overtreatment of women whose prior infections were already treated. Nonetheless, studies conducted in antenatal settings lacking suﬃcient laboratory capacity for RPR testing have found introduction of point-of-care tests greatly enhanced screening rates [22– 24], was acceptable and had negligible risks for women [23, 24], and was highly cost-eﬀective even taking into account some overtreatment [24]. Another commonly reported barrier has been a require- ment that screening and treatment costs are borne by the patient. Provision of free-of-charge or low-cost testing and treatment through government programmes has proven important in some settings to ensure the highest risk women are eﬀectively screened and, if positive, treated [23]. This policy has been found to support health worker’s ability to provide syphilis screening as a routine part of antenatal care, solidifying the habit of universal screening, also important in sustainability [23]. An especially diﬃcult barrier to surmount in many settings is ensuring adequate human resources. In particular, shortfalls in clinical faculty and the absence of training and student mentoring opportunities can complicate strategies for eliminating congenital syphilis. As a result, medical, nursing and midwifery trainees not only lack updated professional curricula and learning materials (e.g., on rapid, point-of-care treponemal tests and syphilis treatment algo- rithms) but also lack practical experience. Addressing this requires the inclusion of current curricula and protocols within pre-service education as well as taking opportunities to observe and provide holistic antenatal care in which syphilis prevention and treatment are incorporated into service delivery. Equally important is engaging national accreditation and credentialing bodies in eﬀorts focused on the elimination of congenital syphilis. An additional opportunity for inﬂuencing provider practice is through partnering with global professional associations, such as, the International Federation of Gynecology and Obstetrics (FIGO), the International Confederation of Midwives (ICM) and the International Council of Nurses (ICN). Such orga- nizations are vested in advancing global standards of care within their respective profession and can greatly inﬂuence syphilis prevention (and its appropriate adaptation) in high- burden countries. 6.2. Health Systems Strengthening. Supporting the creation of strong, sustainable health systems that are responsive, 5 eﬃcient and equitable is now recognized as a key component of improving health for all [25–27]. The 2005 “Paris Declaration on Aid Eﬀectiveness” emphasizes such health systems strengthening through local ownership (of the inter- vention), support of local health systems, harmonization of donor investment (thereby avoiding duplication), results measurement, and agreement of mutual accountability for attainment of development objectives [28]. Similar with other health initiatives, WHO has addressed this in some detail in the four pillar strategy identiﬁed for the global initiative for the elimination of congenital syphilis [20]. However, an inherent challenge lies in striking an appro- priate balance between achieving programme and disease- speciﬁc goals while at the same time ensuring long-term sustainability through well-functioning and adequately- resourced health systems. This challenge also provides an opportunity in that investments that strengthen health systems can be leveraged to ensure that, in nations with high perinatal morbidity, congenital syphilis interventions are part of the comprehensive MCH systems strengthening eﬀorts. Similarly, partnering with other global health initia- tives such as the Global Fund (To Fight AIDS, Tuberculosis and Malaria) [25] and the President’s Emergency Plan for AIDS Relief (PEPFAR) [26] can help support congenital syphilis interventions that are provided to the same at- risk population. The shared goals of improved infant and maternal health encompass the areas of service delivery, healthy workforce development, information needs, medical products and technologies, ﬁnancing, leadership, and gover- nance [27]. 7. Summary Untreated maternal syphilis infection continues to account for large numbers of perinatal deaths worldwide, primarily in nations with moderate to high community prevalence of syphilis and weak health systems. These perinatal deaths are preventable with suﬃciently early antenatal syphilis screen- ing and prompt treatment of women testing positive. This highly cost-eﬀective intervention has been demonstrated to be successfully achieved in several high-burden settings through strengthening current health systems. Now—in the context of Millennium Development Goals aimed at promoting infant health and averting preventable deaths— is a prime opportunity to address this old disease through promoting stronger antenatal health systems. The 2007 WHO initiative for the global elimination of congenital syphilis provides a framework for this eﬀort. The monitoring and evaluation plan developed with support from representatives of high-burden nations provides a means of ensuring progress and accountability through enhancing existing data systems. In addition, the Investment Case developed by WHO and partners oﬀers a potential to identify the resources needed to achieve congenital syphilis elimination over the next ﬁve years in ten of the world’s high- est burden countries. Evaluations of current programmes have helped identify several of the existing barriers to current maternal syphilis screening and treatment eﬀorts as well as potential solutions to address them. Key among these