Supervision of primary health care in costa rica: Time well spent?: Time well spent?

A time-use survey of rural health supervisors (RHSs) and nurse supervisors (NSs) in Costa Rica's primary health care system was carried out to determine whether recently discovered deficiencies in primary health care delivery could be due to inadequate supervision of community health workers (CHWs). The supervisors' recall of their time use in the previous month's work was the basis for the study. Limitations of this type of data are discussed.In Costa Rica, according to Ministry of Health stipulations, supervisors should spend, on average, one day per month observing the service delivery of each CHW. Results of this time-use survey indicated that supervisors spent 59% less time on observing CHWs' performance than was expected. Many NSs did not supervise CHWs through observation, they merely interviewed them. Despite slight differences, no region of the country exhibited adequate supervision. Factors explaining inadequate supervision included: an insufficient number of vehicles for supervisors, inadequate fuel supply, and a heavy additional work load in the health centre for supervisors that reduced their time availability for supervision. Patient consultancies, filling out forms and attending meetings took up the greatest part of the supervisors' time. Conclusions indicate that inadequate supervision of CHWs may explain the results of previous studies that revealed communities with inadequate coverage using child survival interventions.