A review of the economic and programmatic aspects of congenital syphilis was conducted and recommendations made for improvement of its prevention. Congenital syphilis is a preventable disease and the tools to prevent it have been available for decades. In both industrialized and developing countries, but particularly the latter, the prevention of congenital syphilis by antenatal screening is cost-effective and may be cost-saving. Yet, globally, there are probably >500 000 fetal deaths a year from congenital syphilis, a figure rivalling that from mother-to-child transmission of human immunodeficiency virus (HIV), which receives far greater attention. The reasons that congenital syphilis persists vary, with international and national under-appreciation of the burden of congenital syphilis and insufficient political will to provide effective antenatal screening programmes probably being the main reasons. All causes are amenable to effective intervention programmes. The prevention of congenital syphilis should be a global priority; international agencies and national programmes should be committed to improving antenatal care (ANC) services including syphilis detection and prevention.