Resolving the vertical versus horizontal conundrum: the potential of a "next generation" community health worker program to accelerate progress in TB control and at the same time strengthen primary health care.

Building on the experience of the community health worker (CHW) program at BRAC, the largest NGO in Bangladesh and also in the world, as well as on the experience of other successful CHW programs, a "next generation" of CHW programs is being envisioned in which a CHW would visit every home every month. Among many other activities they would carry out, CHWs would screen for symptoms of TB, obtain sputum specimens that would be collected by a supervisor, have them read at a local government laboratory, and then ensure treatment supervision for those who test positive. This is but one example of the power of a full-throated integrated CHW program that could be implemented in low- and lower middle-income countries at a cost of $26 per capita per year and generate over 20 years a 13:1 return on investment. Unfortunately, at present progress in achieving the health-related Sustainable Development Goals is far below what is needed in order to achieve in 2030 the success that was envisioned. Investing in stronger CHW programs and strengthening community-based primary health care has the potential to accelerate progress and at the same time resolve the vertical versus horizontal conundrum.