Market landscape of penicillin for syphilis and rheumatic heart disease, WHO South-East Asia Region

Objective: To assess the market landscape of penicillin formulations used for the treatment of syphilis and rheumatic heart disease in the World Health Organization South-East Asia Region. Methods: We analysed market data for five essential penicillin formulations across nine countries in the South-East Asia Region using a survey form to collect data on product registration, inclusion in national essential medicines lists, procurement, availability, pricing and demand forecasting. Findings: Substantial disparities exist in registration status, procurement and pricing across the region. The price of benzathine benzylpenicillin 1.2 million international units (IU) in Timor-Leste was over 23 times higher than in Bangladesh (3.45 United States dollars, US$, versus US$ 0.15), while the price for 2.4 million IU varied by up to 55-fold across the region. Several countries reported supply issues, including shortages of benzathine benzylpenicillin in India, Maldives, Myanmar, Thailand and Timor-Leste; aqueous benzylpenicillin in Sri Lanka during the 2022 economic crisis; and supply disruptions of phenoxymethylpenicillin 250 mg in Maldives and Sri Lanka. Morbidity-based estimates indicated annual regional demand of 171 966 061 vials of benzathine benzylpenicillin 2.4 million IU and 923 053 121 tablets of phenoxymethylpenicillin 250 mg, with corresponding costs of US$ 62 127 441 and US$ 48 005 181, respectively. India has the highest demand of these two formulations. Conclusion: Differences in registration, procurement, pricing and forecasting undermine reliable access to penicillin products in the South-East Asia Region. Stronger regional collaboration, improved forecasting, harmonized regulatory approaches and pooled procurement strategies are needed to secure equitable and sustainable access.