In 2023, syphilis testing during pregnancy in Zambia depended largely on chance — whether a clinic had test kits in stock, whether staff were trained to use them, and whether follow-up systems worked.
At Shampande Clinic in rural Southern Province, just 4% of pregnant women were screened. At the same time, an estimated half a million dual HIV/syphilis test kits sat unused and expiring in health facilities across the country — procured but idle due to gaps in training, supply coordination, and program oversight.
Recognizing both the need and opportunity, Zambia's Ministry of Health sought to integrate dual testing into routine antenatal care. To accelerate progress, the Ministry partnered with Evidence Action to provide technical assistance: hands-on facility training, supply chain strengthening, and data-driven monitoring.
Shampande Clinic was among the first sites to receive this support. The first cohort of healthcare workers was trained in August 2024, and within months the transformation was evident. By 2025, syphilis screening rates at the clinic had reached 100%. The rate of positive detections increased sevenfold, and every woman testing positive received same-day treatment. According to facility staff, the clinic has not recorded a single syphilis-attributed stillbirth since the program began.
"That pregnancy ended in a healthy delivery, something we attribute to the early detection and intervention."
This transformation at the facility level is reflected nationwide. Across 837 health facilities trained in the program's first phase, independently verified data show that syphilis screening coverage reached 90% in 2024, up from a 45% baseline prior to technical assistance. National coverage reached 75% in 2024, with 86% of those testing positive receiving treatment. With Phase 2 expansion launched in December 2024 and now reaching roughly 80% of Zambia's pregnant women, the program is positioned to drive further gains.
These results are derived from a comprehensive facility survey — combining direct provider assessments, physical commodity counts, and register reviews, validated against national health information systems — ensuring data quality and comparability across provinces. Importantly, the survey revealed that syphilis prevalence among pregnant women is more than double previous national estimates, underscoring both the urgency and the high return on further investment.
The Systems Problem We're Solving
Maternal syphilis illustrates a persistent pattern in global health: we have proven interventions, but they don't reach the people who need them most. A single penicillin injection can prevent more than 80% of adverse outcomes, yet testing and treatment rates in many countries remain low.
Part of what makes this intervention so neglected is syphilis's invisibility. Most women never know they're infected — the infection is largely asymptomatic, with physical signs that appear briefly and resolve on their own. Babies born with disabilities from congenital syphilis (blindness, deafness, physical deformities) typically aren't diagnosed as having syphilis-caused conditions. This invisibility has kept maternal syphilis off priority lists despite its extraordinary tractability and the devastating outcomes it causes.
The gap in Zambia wasn't about clinical knowledge alone, commodity availability alone, or data systems alone. It was about how these elements intersect at the last mile. Testing was slow and unreliable. Treatment was delayed or missed entirely when women left facilities before results returned. Supply chains failed at the last mile because syphilis commodities weren't integrated into HIV supply pipelines. Data systems couldn't distinguish real gaps from recording errors.
The Ministry of Health recognized these problems. What they needed was a partner who could help diagnose bottlenecks systematically, co-design solutions that worked within existing infrastructure, and build capacity for independent operation at scale.
Measuring What Actually Works
Evidence Action's approach in Zambia was designed around a core principle: you can't improve what you don't measure rigorously.
The 2025 Comprehensive Facility Survey, conducted in February and March 2025, provided an in-depth assessment of service delivery quality across Zambia's first 837 trained facilities. Using probability-proportionate-to-size sampling, 44 sites were selected to represent the full range of facility types and geographic settings.
The findings tell a clear story about where health systems interventions succeed and where challenges persist:
- Training works. 95% of providers correctly identified appropriate syphilis tests based on HIV status; 100% knew correct treatment guidelines. The cascade training model achieved its core objective—healthcare workers know what to do.
- Supply chain integration works. 97% of facilities had testing supplies in stock; 94% had treatment available. By integrating syphilis tests into established HIV supply pipelines, the program solved the erratic availability problem that previously plagued syphilis services. This integration addresses genuinely connected health challenges: in Zambia, 20-40% of women with HIV also have syphilis, and co-infection increases HIV transmission risk to babies.
- Patient acceptance is high. 90% of providers reported zero testing refusals over the preceding three months. The barrier to coverage isn't patient resistance—it's system capacity. The 21% treatment gap (79% treatment coverage among trained facilities) reflects specific challenges: women diagnosed with both infections in the same appointment sometimes decline syphilis treatment due to overwhelming information; some want to consult partners before treatment; periodic stockouts prevent same-day availability.
- The remaining gaps are operational, not structural. The 10% screening gap (90% coverage among trained facilities) reflects addressable challenges: periodic stockouts, documentation inconsistencies, provider turnover requiring refresher training.
- Impact extends beyond directly trained facilities. With Phase 2 now complete, the program reaches health facilities which serve approximately 80% of pregnant women nationally. National screening coverage at 75% represents dramatic improvement from the 45% baseline—demonstrating how systematic health systems strengthening creates ripple effects beyond directly trained sites.
Sustaining the Momentum: A Proven Model, Poised for Scale
The success at Shampande Clinic and across Zambia is not an isolated story — it represents a model that is working across countries and ready to reach millions more.
Liberia
National coverage of syphilis testing in pregnancy has grown from 8% to 88% since 2020, and 94% of women testing positive now receive treatment. More than 500,000 women have been screened, preventing an estimated 1,900 adverse outcomes and saving over 1,000 lives. Four of the country's fifteen counties have already graduated to full government ownership, and the rest are preparing to transition.
Cameroon
The Ministry of Public Health has led a rapid expansion of dual HIV/syphilis testing since 2022, with over 1,600 health facilities and 16,000 healthcare workers trained. National data systems are now capturing results in real time — enabling the Ministry to plan expansion to 1,000 additional facilities with support from Global Fund, PEPFAR and other partners.
Evidence Action was recently selected as an awardee of the Action for Women's Health initiative — a $250 million global call funded by Melinda French Gates' Pivotal — chosen from over 4,000 organizations across 119 countries. This recognition validates what the data already shows: systematic technical assistance works.
With this support, Evidence Action will partner with additional countries in Africa and Asia to integrate syphilis screening and treatment into routine prenatal care. The opportunity is immediate: many countries are already procuring dual HIV/syphilis tests but need targeted support to deploy them effectively. The foundation is in place — trained providers, functioning systems, reliable data, and a track record of measurable results across diverse health system contexts.
The Challenge Ahead
The challenge now is scale. How quickly can we bring this lifesaving approach to the millions of pregnant women still at risk of a preventable infection? Can expansion happen at the pace the evidence supports?
The program remains one of the most cost-effective opportunities in global health — a rare chance to save lives, strengthen systems, and close a long-ignored gap in women's health.
Notes
1 WHO defines interventions as "highly cost-effective" when they cost less than a country's GDP per capita per DALY averted. Zambia's GDP per capita is approximately $1,200. At $20 per DALY averted, the Syphilis-Free Start program in Zambia is approximately 60 times more cost-effective than this threshold ($1,200 ÷ $20 = 60).
2 According to our 2025 Comprehensive Facility Survey, syphilis prevalence among pregnant women in Zambia is 6.7-7.9%, more than double the 3.0% estimate used when scoping the program in 2021. This discovery, based on direct register review across 44 facilities, transforms the program's impact calculus. With approximately 770,000 pregnant women attending antenatal care annually in Zambia: At 3% prevalence: ~23,000 infections annually. At 7% prevalence: ~54,000 infections annually. The difference represents thousands of additional babies at risk of stillbirth, neonatal death, or lifelong disability from congenital syphilis — and thousands more opportunities for intervention to prevent these outcomes.