Developing and implementing training materials for integrated community case management in South Sudan

Learning Paper

Developing and
implementing
tr aining
materials
for integrated community case
management in South Sudan

[ 2 ]

The Learning Papers Series
Since starting operations in 2003, Malaria Consortium has
gained a great deal of experience and knowledge through
technical and operational programmes and activities relating
to the control of malaria and other infectious childhood and
neglected tropical diseases.
Organisationally, we are dedicated to ensuring our work remains
grounded in the lessons we learn through implementation.
We explore beyond current practice, to try out innovative ways
– through research, implementation and policy development –
to achieve effective and sustainable disease management and
control. Collaboration and cooperation with others through our
work has been paramount and much of what we have learned
has been achieved through our partnerships.
This series of learning papers aims to capture and collate some
of the knowledge, learning and, where possible, the evidence
around the focus and effectiveness of our work. By sharing this
learning, we hope to provide new knowledge on public health
development that will help influence and advance both policy
and practice.
Developing and implementing training materials
[ for integrated community case
management in South Sudan ]
Authors:
Susan George

Consultant

Madeleine Marasciulo

Senior Case Management Specialist, Malaria Consortium

Contributors:
Bridget Brown
Programme Manager, Malaria Consortium South Sudan

David Lukadi
ICCM Programme Officer, Malaria Consortium South Sudan

Dr. James Ssekitooleko
Project Coordinator, CIDA ICCM, Malaria Consortium Uganda

Dr. James Tibenderana
Africa Technical Director, Malaria Consortium

Emily Keane
ICCM Nutrition Programme Coordinator, Malaria Consortium South Sudan

Helen Counihan
Regional Programme Coordinator, CIDA ICCM, Malaria Consortium

Miatta Zenabu Gbanya
Technical Coordinator, Malaria Consortium South Sudan

Ruth Allan
Country Director, Malaria Consortium South Sudan

Salim Nakuiera
Programme Officer, Malaria Consortium South Sudan

Mike Ahern
Paula Valentine
Consultant

Editor:
Diana Thomas

Senior Communications Manager, Malaria Consortium

Contact:
learningpapers@malariaconsortium.org
Photo: Jenn Warren / Malaria Consortium

CONTENTS
[ 2 ] Introduction
[ 3 ]
Background
Republic of South Sudan
The health care system
ICCM in South Sudan
Malaria Consortium’s implementation of ICCM
[ 9 ]

Initial ICCM training
implementation and review
June 2010 – 11
Lessons learnt during initial training

[ 14 ]

M
id-term review
October 2011

[ 16 ] ost review ICCM
P

training implementation
December 2011 – March 2012
[ 21 ]

P
ost-revision ICCM training implementation
April 2012 onwards

[ 22 ]

Lessons learnt

[ 24 ] About Malaria Consortium

[ 2 ]

Introduction
ICCM in the community

South Sudan

This paper shows how best practices for
delivering training of Community Drug
Distributors (CDDs) in the implementation
of integrated community case management
(ICCM), that have been shown to be
successful in some countries and contexts,
needed to be adapted to fit a more complex
environment in South Sudan.

It also shows how adaptation of materials is
a resource intensive, proactive and on-going
process, which requires testing existing best
practices and evaluating which systems,
methodologies and tools can be used in
various settings, as opposed to those that
require additional revising or innovation.
Malaria Consortium went through a process
of applying innovative strategies to develop
materials and implement ICCM training
in two states of South Sudan between
June 2010 and June 2012 at a time when

CDDs being trained in ICCM in
South Sudan

the Ministry of Health was still developing
strategy, policies and its approach to ICCM
programming. During this process the
effectiveness of training was evaluated
and revised to ensure CDDs learned good
standards of care that would have a positive
impact on the health of the communities
they served.
This paper looks at the process and the
challenges encountered, and considers the
lessons learned from implementing ICCM
training in this complex setting.

[ 3 ]

Background

Republic of South Sudan
The Republic of South Sudan became an
independent nation on 9 July 2011 following
a referendum on self-determination in
January 2011 where 99 percent of South
Sudan’s population voted for independence.
The referendum brought to an end the
2005 Comprehensive Peace Agreement
and ended over 20 years of civil war which
had resulted in the deaths of over two
million people.
The first year of sovereignty has brought
a number of challenges. The government’s

austerity measures have cut its already
limited financial support to basic services,
including healthcare. The economy and
new currency are also approaching collapse.
The failure to agree on citizenship issues
has resulted in 400,000 Southern Sudanese
being forced to move from Sudan to South
Sudan since October 2010. These returnees
– combined with military conflict with the
Republic of Sudan, ethnic conflict within
South Sudan, food insecurity and flooding –
are contributing to mass displacement both
across the border and within South Sudan.

[ 4 ]

The UN estimates that 4.7 million South Sudanese are at risk
of food insecurity due to dry weather, flooding and high
food prices, and forecasts for the coming harvest (2012) are
low. Malaria cases are currently at a level the World Health
Organisation (WHO) has described as ‘epidemic’.
In rural areas access to healthcare is very challenging. Malaria
Consortium has been pioneering a community model in
South Sudan which is, we believe, one way that access to care
can be improved, leading to a reduction in child mortality.
The population of South Sudan is estimated at eight
million. There are over 250 ethnic groups that vary in
cultural beliefs and traditional practices. In Northern
Bahr el Ghazel (NBeG) the majority of people are Dinka
(Dinka-Malual) with a minority Luo, while in Unity state
the predominant tribe is Nuer, with a minority Dinka
(Dinka-Ngor). The culture of the populace is largely
nomadic pastoralist and agro-pastoralist, with some
spatial sedentary farming groups.
As it is common for men to have more than one wife, families
tend to be large and there are often many children under-five
in a household. This means that there can be high numbers

of children in a CDD catchment area, estimated at around
40 households per CDD.
However, the settlements are sparsely located making the
geographical expanse of the catchment area very wide.
Sanitation is a concern everywhere, and many households
struggle to access clean water. Open defecation is common
practice in both rural and urban areas.
Decades of conflict in South Sudan have led to a collapse
of infrastructure in the country. Globally, South Sudan has
some of the worst social indicators, particularly in the health
and education sectors. It has the second highest illiteracy
rate in the world with most people illiterate or semi-literate.
Government figures indicate that just 27 percent of the
population is literate – 40 percent men, 16 percent women
(National Baseline Household Survey 2009, Statistical
Yearbook for Southern Sudan 2010). This poses a challenge
as the majority of the volunteer CDDs are low-literate
women. In NBeG, most people speak either Dinka or Luo,
but cannot read or write in these languages. Some may have
Arabic and English as subsequent languages, but not as their
first language. General levels of education are very low.

[ 5 ]

Background

The health
care system
The health system of South Sudan, despite the efforts of the government, donor,
international non-governmental and national organisations, still faces numerous
challenges related to lack of qualified and limited human resources, drugs and medical
supplies shortage and availability of functional health facilities providing the basic
package of health services for the population.
According to the South Sudan Health Facility Mapping (2011), it is estimated that
44 percent of the population are settled within a five kilometre radius of a functional
health facility. Out-patient visits are estimated at 0.2 visits per person per year.
A combination of factors has led to this low use: lack of qualified staff, inadequate
equipment and supplies in the county and state hospitals, long distances to the health
facilities, poor roads and transport, limited or no ambulance services, a dysfunctional
referral system, and cultural and financial barriers. Most health workers need significant
in-service training as a result of the short and poor quality of their pre-service training. The
majority of health facilities are public or private not-for-profit and are scattered throughout
South Sudan in both rural and urban areas. However, even where health facilities do exist,
the quality of services has been low due to frequent stock outs of medicines, inadequate
staffing and supervision, as well as lack of appropriate equipment and supplies.
Primary Health Care Units (PHCU) are the most basic form of health facility in South
Sudan. PHCUs can be one room in a village, with typically with one to three health
workers, a cleaner and a guard. Primary Health Care Centres (PHCC) are slightly larger,
and are found in larger villages or towns. Health facilities are more often staffed by
clinical officers, nurses and midwives, rather than doctors. There are very few hospitals
found in the country, which could offer a wider variety of services.
There is a seasonal variation in malaria transmission, with the largest numbers of cases
observed during the rainy season from May to November often peaking in September.
In the dry season pneumonia, diarrhoea and malnutrition remain a problem. Access to
clean water becomes a significant challenge in some areas. Malnutrition peaks in the
‘hunger gap’ from April-September when food security is at its lowest.

Child mortality
South Sudan has a high burden of communicable diseases with correspondingly
high mortality. It has one of the highest childhood mortality rates in the world,
largely attributed to malaria, acute respiratory infections and diarrhoeal diseases,
often associated with under-nutrition. The Sudan Household and Health Survey
(SHHS) conducted in 2010 showed that the infant and under-five mortality per
1,000 live births is 75 and 105 respectively, and 28 percent of children under-five
were severely underweight, 31 percent had stunted growth and 23 percent had
severe wasting.

South Sudan community village

[ 6 ]

Background

ICCM in South Sudan
In South Sudan, ICCM is carried out by
trained community volunteers called
community drug distributors (CDDs)
or community based distributors.
These operate like community based
(volunteer) health workers in other parts
of Africa but are known differently as,
in South Sudan, a community health
worker operates within the Ministry of
Health (MoH) structure, receiving around
nine months training to provide health
services at the PHCC / PHCU levels.
South Sudan has experienced a great deal
of success in increasing access to health
services through ICCM. The International
Rescue Committee’s (IRC) pioneering work
has become the foundation for ICCM
implementation in South Sudan, which
Save the Children, Population Services
International (PSI), Malaria Consortium,
BRAC and Catholic Diocese of Torit (CdoT)
have all adopted. IRC South Sudan’s Child
Survival Programme has demonstrated
that, when CDDs are properly trained
and supervised, a community based
treatment programme is feasible even in
a post-conflict setting. CDDs are able to

deliver life-saving treatment to children
that would otherwise have no access to
medical treatment. Based on evidence of
feasibility and impact on malaria morbidity
and mortality, WHO and the Roll Back
Malaria partnership endorsed the home
management of malaria strategy as a
key element of the global malaria case
management strategy. ICCM started
with the introduction of the home
management of malaria programme as
part of a comprehensive community based
child survival strategy fashioned around
the principles of community integrated
management of childhood illnesses.
The MoH has promoted an integrated
approach to child survival interventions
to minimise the phenomenon of
‘replacement mortality’, whereby
children whose lives are saved from one
disease e.g. malaria, end up dying from
other conditions such as diarrhoea or
pneumonia. The integrated community
based child survival programme comprises
three main technical strategies: treatment
of malaria, pneumonia and diarrhoea by
community providers, improved capacity

to treat childhood illnesses at heath
facility level, and improved quality
of care in the private sector.
The MoH and its partners are working
towards scaling up an integrated
child survival programme that delivers
treatment for malaria, pneumonia,
diarrhoea and severe acute malnutrition
with key messages on other common
childhood illnesses. A turning point for
the renewed support by the MoH for
ICCM programming was stimulated in
June 2012 when MoH representatives
from South Sudan attended an ‘ICCM
gap analysis and filling the funding
Gap’ workshop facilitated by UNICEF
and AMREF, where an ICCM taskforce
was formed for the development of an
ICCM proposal for the country. Through
Malaria Consortium’s programme for
ICCM, implementing agencies and the
MoH are working together for the
harmonisation of ICCM implementation
strategies, interventions, tools and
training manuals.

ICCM implementing partners
Currently there are six ICCM implementing partners (IRC, Malaria
Consortium, CDoT, PSI, Save the Children and BRAC) in South Sudan.
ICCM is currently being implemented in nine out of the 10 states and
in 32 counties, with NGOs generally funded by different donors to
implement certain components of the ICCM package.

[ 7 ]

Integrated community
case management
The term integrated community case
management (or ICCM) generally
refers to an integrated approach for
assessing and classifying signs and
symptoms of pneumonia, diarrhoea,
and malaria in children under five
years old, and providing home-based
treatment or referral for these diseases.
The approach also normally includes
health promotion activities.
This care is provided by volunteers in
the community who are trained by
health workers on the ICCM approach.

A CDD carries her drug box through the mud to
her village, Kumagong, Unity State

[ 8 ]

Background

Malaria Consortium’s
implementation of ICCM
Malaria Consortium’s ICCM programme
in South Sudan is supported by the MoH
and has been funded by a range of donors
including The Global Fund to Fight AIDS,
Tuberculosis and Malaria, CIDA, Common
Humanitarian Fund, and USAID ADRA-SSHiNE.
The community level focus is on diarrhoea,
malaria, pneumonia and severe acute
malnutrition (SAM). Given the inextricable
links between disease and malnutrition,
and the chronic levels of acute malnutrition
in South Sudan, Malaria Consortium
integrated SAM into the full ICCM package.
This approach is becoming more recognised
and practiced globally, however, at time of
writing, Malaria Consortium is the only NGO
using this approach in South Sudan.
Malaria Consortium has implemented ICCM
programmes in two states: NBeG and Unity.
Unfortunately, the Unity programme, which
was operational for three years, had to be
closed in June 2012 after prolonged access
restrictions created by insecurity.

CDDs are shown how to use the job
aid for diagnosis and treatment

Malaria Consortium has successfully
contributed to the development and
implementation of ICCM and other community
health training in Uganda, Mozambique
and Zambia using and / or adapting training
materials developed by WHO / UNICEF and
Save the Children. ICCM is currently the
community health care model used by the
Ministry of Health in these countries.
These successes underpinned the decision
by Malaria Consortium to apply these best
practices in the implementation of ICCM in
South Sudan. Established training manuals
were adapted and subsequently used to
train trainers, CDDs and their supervisors.
However, applying best practices by
adapting the ICCM materials for a diverse
context created additional challenges, which
became apparent following a review of the
programme after a period of implementation.
The recognition of these challenges and their
potential impact on quality of community
care, and the process in which they were
addressed and evaluated follow.

[ 9 ]

Initial training implementation
and review
June 2010-11

A total of

1,610 CDDs
and

112 CDD
supervisors
were trained during
initial implementation

The initial training materials developed were
based on the WHO/UNICEF gold standard
and the successful implementation of ICCM
training in Uganda. The materials included:
ICCM Training Manual
Training of Trainers Guide
Sick Child Job Aid

in Uganda. This meant that the assessment,
classification, referral, treatment, and
recording skills were done by focusing on
a different disease or condition each day.
However, the materials were adapted to
include additional demonstrations, role play
activities, interactive games and instructions
for using the Sick Child Job Aid and CDD

CDD Flipbook

Flipbook in recognition of the low literacy

CDD Recording Form

context of South Sudan.

R
eferral Triangles used to track referral
of sick children to the PHCC / PHCUs

A training cascade system was used to

T
reatment Cards containing child
treatment instructions for caregivers

Consortium technical and adult learning

CDDs are also given and taught how to
use a respiratory timer to count number of
breaths in a child with possible pneumonia,
a mid-upper arm circumference (MUAC) tape
to measure the arm of a child with possible
acute malnutrition, and medications to treat
malaria, pneumonia and diarrhoea.
The technical design in the initial ICCM
Training Manual followed the same ‘disease
by disease approach’ used for ICCM training

deliver the training. This involved Malaria
experts training South Sudanese county
health facility officers to become ‘master
trainers’. The master trainers in turn trained
a larger group of ‘core trainers’ through
a series training of trainers (TOT) using
the TOT Guide. The core trainers were
health facility workers who, in some cases,
reported to the health facility officers. After
the TOT, the master and core trainers were
responsible for delivering a six-day ICCM
training to CDDs in their communities using
the ICCM Training Manual.

Training the trainers
The first of a series of TOTs in NBeG and Unity States began in June 2010. The TOTs
covered the ICCM approach of assessment, classification, referral and treatment of
malaria, pneumonia and severe acute malnutrition (but not diarrhoea), as well as
adult learning and participatory training methodologies. Four master trainers and
20 core trainers who completed the TOT from Aweil and Bentiu, went on to train
county health department trainers (CHDs) who then went on to train the CDDs.

[ 10 ]

Initial ICCM training implementation and review

Lessons learned during the
initial training
Malaria Consortium supervised the initial
cascade training and evaluated the technical
and training capacity of the trainers. The CDDs
were also evaluated at the end of each
training to assess their understanding of the
training content and materials. Although
individual components of the ICCM material,
such as the Sick Child Job Aid, the CCD Flipbook
and Referral Triangles had been pre-tested
in several places in South Sudan, the full
ICCM training course had not been field
tested with the same group of CDDs in the
country. Some lessons identified during
this initial training implementation are
highlighted below.
During the training, core trainers, CDD
supervisors and observers, saw that the
CDDs did not completely understand key
content from their training. For instance,
many CDDs found it difficult to count the
number of breaths a child took in one
minute, which is key to assessing if they have
pneumonia. This difficulty came about for
a number of reasons including: counting
the ‘ticking’ sounds of the respiratory timer
rather than the child’s breaths; remembering
the thresholds for ‘fast breathing’ for the
different age groups; and, in some cases, not
being able to count to numbers higher than
10 or 20. This issue is not unique to South
Sudan, however the levels of illiteracy and
low numeracy amplified the challenge and
how to respond to it. There was a concern
that CDDs would treat children incorrectly
by assessing a cough as the only symptom
of pneumonia, leading to overtreatment
with antibiotics. This was supported by
the routine treatment data received from
programme implementation, which showed
a high number of cases of cough alone
(without fast breathing) were being treated.

After the full ICCM training course had
been implemented with the CDDs in Unity
state, observations from CDD Supervisors
indicated that some of the CDDs did not
understand the ICCM tools such as the
Sick Child Job Aid and CDD Flipbook.
The experiences from the training
implementation in Unity State made it
necessary to assess if there were significant
gaps in the knowledge and skills of the CDDs in
NBeG and to determine if there were potential
risks of under- or over-treating sick children.
This would allow the team to map out risk
thresholds for the programme and focus on
topics which could not be compromised.
At this point trainers were also realising that
the training was hard to deliver effectively.
There were a number of reasons for this,
including the fact that too much time had
elapsed between the original TOT and
the roll-out of the CDD trainings. Many of
those trained initially had since left their
jobs, which meant that the few trainers left
were over-stretched and found it difficult
to manage the level of roll-out. In addition,
the technical content of the training was
more demanding for the South Sudan
context than originally anticipated.
Because of these and other field experiences,
it was decided to carry out a mid-term
review to evaluate the technical elements
of the training curriculum and all the
materials. The full roll-out of the complete
ICCM programme was postponed and
Malaria Consortium’s broad technical
experience was drawn upon to help
address some of these concerns.

ICCM trained CDD, Rebecca Alang,
explains her diagnosis of one-year-old
Athiang Bol in Kumagong, Unity State

Developing and implementing training materials for integrated community case management in South Sudan

[ 12 ]

Mid-term review
October 2011
The mid-term review took place over three
weeks during September and October 2011.
Technical reviewers included the ICCM
Project Manager for Malaria Consortium
Uganda and team members from Malaria
Consortium in Unity and NBeG. The mid-term
review involved evaluating:
T
he training cascade process and
trainer capacity
T
he master’s and trainers’ abilities to
deliver the ICCM content to the CDDs
T
he technical content of the trainer
and CDD training materials
C
DD capacity and how CDDs were
assessed at the end of training
P
ost training CDD capacity strengthening
The mid-term review of training implementation
took place in two areas of NBeG; one through
direct delivery of the training to the CDDs in
Dinka and the other with training content
delivered through translation.

CDDs newly trained in ICCM,
Tor village, Kumagong, Unity State

Mid-term review
findings:
1 Training cascade process
and trainer capacity:
It was found that the training cascade
system hindered the delivery and transfer
of consistent information by the time
it reached the CDDs. In several cases,
incomplete content or diluted messages
were delivered to the CDDs. Additionally,
from the time the first pilot TOTs were
delivered to the refresher trainings in
August before implementation of ICCM
commenced, several of the best trainers had
left to work for NGOs. Few trainers were
still working within the MoH, while those
who remained did not have the appropriate
skills and experience needed to implement
the cascade training. County health
department and health facility staff were
over stretched trying to deliver services
through the formal system.

[ 13 ]

2 Trainers’ ability to train
CDDs in ICCM:

3 The technical content of the
trainer and CDD training materials:

The initial ICCM Training Manual
assumed that the master trainers
and core trainers had a level of
ICCM capacity and skills to be able
to accurately interpret and translate
the technical content in the training
material in a way that CDDs would
understand. This has always been the
case in other countries and is based on
WHO guidelines for implementation.
Normally, a few subject-matter experts
train a small group of core trainers who
then train a large group of health care
workers and community volunteers.

The initial ICCM Training Manual was
reviewed for gaps in technical and ICCM
content. The following questions arose:

In South Sudan there is neither the
required capacity nor number of
healthcare providers to deliver quality
training to CDDs. Although some
trainers did an excellent job, several
of the master and core trainers
demonstrated a limited ability to
discern which content CDDs needed to
learn and to disseminate the content
to CDDs in a manner that could easily
be understood. In addition, despite
the pre-testing work that went into
the development of the initial ICCM
Training Manual, the trainers had visible
difficulty following the instructions.
They also had difficulty translating the
clinical information for an audience
with no clinical knowledge and in
some cases who spoke a different
language than the trainer. Without
this tailored communication, the
effectiveness of the training process
would be severely compromised.

c
ould CDDs detect fever without
a thermometer?
c
ould age-based treatment on a
severely underweight child be harmful?
c
ould misdiagnosis lead to overtreatment with antimalarials and
antibiotics, potentially leading to
drug resistance?
It was found that although the initial
ICCM Training Manual contained
correct information, there were some
technical elements and clarifications
that could be added.
The levels of literacy and numeracy
among CDDs were far lower than in
other countries where ICCM is used.
This meant that using conventional
adult training techniques or training
tools, which required CDDs to read,
write or count, proved difficult. Besides
CDDs not being able to count the number
of breaths, Malaria Consortium also
recognised that CDDs had difficulty
understanding the drug dosing
instructions in the Sick Child Job Aids.
CDDs were confused by having both a Sick
Child Job Aid and a CDD Flipbook. The
Sick Child Job Aid was designed to give
the CDDs a quick reference to assess and
refer sick children. The CDD Flipbook was
designed to be used by the CDD with the
child’s caregiver to give specific care and
treatment advice. There was overlap of the
information in both tools which had been
intended to reinforce content and key
messages. CDDs were unsure when to use
which tool and were not clear what the
difference was between the two.

4 CDD capacity assessment
and post training CDD capacity
strengthening:
During the mid-term review a randomly
selected group of CDDs were observed
carrying out ICCM activities and their
knowledge was assessed through
interviews to determine how much they
had grasped or remembered of the
information presented during the training.
Through skill observations and interviews
it was found that the CDDs did not
respond well to the method of teaching
diseases individually and struggled to
convert a disease by disease system into
a holistic approach. This was particularly
the case when children presented with
more than one condition, which appeared
to be relatively common in the context.
Training ICCM through a disease by
disease structure, which had proven
to be a feasible approach to training
community volunteers in Uganda, proved
challenging to CDDs in South Sudan.
Additionally, the delay between when
the TOT was delivered and when the
CDDs received training subsequently
was sometimes too long for the
trainers to retain what they had
learned sufficiently.
The initial training implementation
included recommendations for an
end-of training evaluation of the CDD
skills, although there was no formal
CDD competency checklist or process.
Therefore CDD competencies were not
appropriately assessed at the end of
training. Supervision training and the
supervisory competency checklist were
not developed as part of the initial
ICCM package, and when included at a
later stage, were not fully implemented
for security reasons.

[ 14 ]

Mid-term review
recommendations
The following recommendations were made
as a result of the mid-term review findings:
C
hange the structure of training manual
and materials from teaching by disease,
to teaching an integrated and holistic format
of assessment, classification, treatment,
referral, and recording of all illnesses
Include additional innovative training and
communication strategies in the revised
training ICCM Training Manual and Sick Child
Job Aid to reflect the new holistic format
and address the low literacy among CDDs
T
rain the trainers on the revised manual
and CDD training tools and provide
additional capacity building in technical,
adult learning and supervisory skills
F
ield test newly developed or revised
training materials and assessment tools
and assess trainer’s abilities to use them
Develop assessment tools to measure CDDs

competencies to deliver each stage of the
ICCM approach to ensure confidence in
their skills to treat appropriately
D
evelop assessment tools to measure
trainer and supervisor competencies to
deliver training consistently and to provide
CDDs with performance improvement
feedback and mentoring.

Malaria Consortium child survival officer,
Samuel Majek, discusses the use of ICCM
assessment materials with a CDD

[ 16 ]

Post review ICCM training
implementation
December 2011 – March 2012
As part of the post review process, Malaria
Consortium’s case management and health
training specialist, was asked to revise all
the ICCM training materials for NBeG in
collaboration with the technical team in
South Sudan. Malaria Consortium’s response
to the mid-term review recommendations
was as follows:
H
ire a new cadre of trainers to work for
Malaria Consortium as field officers rather
than the county health department
C
onduct a training needs assessment with
the new trainers and existing CDDs to test
revised draft training materials
Revise the technical content of the
ICCM Training Manual to address the
mid-term review recommendations and
also ensure they are consistent with the
new MoH guidelines
T
rain the newly hired field trainers on
adult learning skills, the revised training
materials and supervisory skills
F
ield-test all the revised materials and
delivery of the revised six-day ICCM
training in three communities in NBeG
Revise materials subsequently based
on the field testing

1 Response to the training cascade
process and trainer capacity:
To overcome the problem of messages
becoming diluted down through the
cascaded training, Malaria Consortium
hired and trained experienced health facility
workers to become Malaria Consortium
field trainers. As a result, the core trainer
component of the training cascade was
eliminated. Malaria Consortium conducted a
quality selection process in order to employ,
train and supervise 20 field trainers to deliver
the ICCM training and supervise the CDDs
in NBeG. These field trainers were nurses,
health workers or clinical officers and, in
some cases, had previously received training
as ICCM master or core trainers during the
initial training period by Malaria Consortium,
but who for other reasons had left the public
health sector. Malaria Consortium also hired
several project officers with more advanced
medical or management skills, and both a
project manager and a programme manager
were employed to supervise the field
trainers’ performance and ensure continued
quality improvement.

Result
There was a significant increase in
the number of trainers that had
previously been recruited to deliver
this training, from five to 20.

[ 17 ]

2 Response to trainers’ ability
to train CDDs in ICCM:
One of our field officers
participated [in the field
testing of the manual]. The
manual looks good and
we are trying to see the
possibility of integrating it
into the current manual for
the Ministry of Health

Dr Elsheikh Abdalla,
Community Case Management
Coordinator,
International Rescue Committee,
South Sudan

During the training needs assessment
conducted in February 2012, the newly
hired field trainers were assessed for basic
ICCM and adult learning knowledge and
skills. As a result of this assessment, Malaria
Consortium conducted another set of TOTs
to train field trainers and project officers in
adult facilitation skills, how to deliver the
revised ICCM training materials, in-service
training on integrated management of
childhood illness (IMCI), and management
and supervisory skills. During these TOTs,
trainers learned to follow simple algorithms
to teach the integrated disease approach
and how to teach progressive chunking
of content, repetition of key concepts
and interval reinforcement to ensure
CDDs’ retention. A trainer competency
checklist was developed to assess the
trainer’s technical and training skills, and
a supervisor competency checklist was
developed to assess the trainers’ skills
delivering feedback to CDDs during and
after training.
During the assessment the field trainers
were asked to describe the challenges
presented by translating technical content
from a training manual written in English
into various local languages. In response to
their feedback, the technical content and
facilitator instructions in the ICCM Training

Manual underwent a readability assessment
(Flesch-Kinkaid) and revised to a 5th grade
level. This included replacing complex terms
and words with basic vocabulary, short
concise sentences, and reader-friendly
formatting. Prescriptive step-by-step
technical and participatory training instructions
were used to ensure consistency and
accuracy of the information the trainers
needed translate and communicate to
the CDDs. It also included more practical
instructions on how to use the revised Sick
Child Job Aid, respiratory timer and beads,
the MUAC tape, Referral Triangles, and the
CDD Recording Form. The key competencies
and learning outcomes for each section
were clearly shown and divided into easy
to use sections.

Result
During the field-testing debrief, field
trainers stated the revised ICCM
Training Manual was easy to follow
and translate and made it easy
for the trainers to read, recall and
pass on the information involved,
without necessarily needing a clinical
background. This was significant,
given the levels of education and
literacy in the country.

[ 18 ]

3 Response to technical content
of the trainer and CDD training
materials:
The ICCM Training Manual was
completely rewritten to include the
recommended integrated process:
A
ssessment of the sick child ages two
months to five years: danger signs,
fever, fast breathing and cough,
diarrhoea, SAM, other symptoms
C
lassification, referral and pre-referral
treatment: danger signs, severe
malaria, severe pneumonia, severe
diarrhoea and dehydration, SAM,
and other illnesses
H
ome based treatment and
caregiver advice: Malaria,
Pneumonia and Diarrhoea
R
ecord keeping and management
of medicines and supplies
F
ollow-up and health messages
An Annex of Training Resources was
added which included: technical
resources such as classification, referral
and treatment algorithms, trainer
resources such as how to plan, deliver
and evaluate the training and how to
teach CDDs to give caregiver advice
messages for health promotion and
disease prevention.
In response to the low literacy and
numeracy levels among CDDs, a series
of 48 colour laminated instructional
pictures were developed and used
by the trainers as memorable and
interactive visual aids. The instructional
pictures were used to explain and test
CDDs comprehension of the integrated
process used in ICCM as well to ensure
that CDDs could correctly match the
patient’s symptoms to the diagnosis

and treatment for their age and illness.
Instructional pictures also corresponded
with the pictures in the Sick Child Job
Aid and the CDD Recording Form.
The issue of CDDs’ limited ability to
count above 10, and therefore unable
to count the number of breaths, was
addressed by dedicating a much longer
period of time to training and practicing
how to use respiratory beads along
with a 60 second respiratory timer.
Before introducing the beads into
the programme, Malaria Consortium
piloted their use with several groups
of CDDs in NBeG which, together with
information gained from pilots by IRC
and Save the Children, showed that they
were beneficial in aiding the CDDs to
correctly assess respiratory rate. CDDs
were trained to use one set of beads to
help assess an infant 2-11 months and
another set to assess a child of one to
five years old.
The CDD were trained to select the
correct set of beads based on the child’s
age, set the 60-second timer and move
through coloured beads–one bead per
breath - towards the red beads. If the
CDDs hand reaches the red beads by
the time the timer goes off, they know
the child has fast breathing and needs
treatment. This allowed CDDs to assess
a child without needing to count or to
remember the number of breaths needed
for fast breathing in either age group.
In response to the confusion
experienced by CDDs working with
both the CDD Flipbook and the initial
Sick Child Job Aid, the CDD Flipbook
was eliminated and the Sick Child Job
Aid was revised to include the unique
information from the flipbook.

The revised Sick Child Job Aid also included
all new content incorporated into the
training. New pictures were added for
children’s ages and gender, for assessment,
referral treatment, and for severe acute
malnutrition and dehydration. Simple
descriptive words for the pictures were
added in Dinka and Luo for trainers and
community members who can read. New
prevention and caregiver advice pictures
and messages consistent with the GoSS
guidelines were added.

Result
The instructional pictures were
evaluated during the six-day
training field testing with
45 CDDs and eight health
facility and nutrition officers.
Informal qualitative assessment
found that the instructional
pictures helped the CDDs to
understand the material due to
frequent repetition of the key
content. The language used was
appropriate and the instructional
pictures were representative of
the South Sudan context. The
new job aid is more reflective of
the process that the CDDs are
expected to follow and flows
accordingly. Having only one
tool reduces the decision making
required of the CDD about
which tool to use and when.
Malaria Consortium is planning a
qualitative evaluation with CDDs
on their experience in using the
respiratory beads and revised
Sick Child Job Aid.

[ 19 ]

During the field testing of the revised
training materials in March 2012 it was
discovered that CDDs had difficulty
recording the outcome of a patient visit
and could not accurately insert tick marks
in the correct row and column of the CDD
Recording Form. CDDs did not understand
that each row needed to be completed
in sequence and were confused by where
to correctly intersect a row with the
corresponding column. The initial manual
dedicated one hour on the last day of
training to completing the recording
form. This was based on the ICCM and
CDD training manuals, which presume
that CDDs can place tick marks in boxes.
This was addressed in three ways:
ICCM implementing partner, PSI,
revised the CDD Recording Form
and included the same pictures
used in the Sick Child Job Aid
M
alaria Consortium recommended
that a plastic sliding sheath be added
to the form, which the CDDs can
use to move to slide up and down
to help them find their place along
the correct row. The Facilitator
Guide was revised to include more
in-depth training on how to place
ticks marks in correct boxes for the
corresponding rows and columns.
Practicing recording patient visits in
the CDD Recording Form was added
at the end of each training day.

Respiratory beads
The respiratory beads were developed by one of the South Sudan ICCM
implementing partners, Save the Children, and consist of a string of coloured
(green or blue) beads which lead to a number of red beads at one end. The
number of green or blue beads before the red beads correspond with the cut
off for the WHO definition of fast breathing for both age groups.

[ 20 ]

4 Response to CDD capacity
and assessment and post training
CDD capacity strengthening:

The CDD Competency Checklist is used

One of the recommendations for
the third phase revision process
included the development of a CDD
Competency Checklist and a system for
certifying CDDs competencies at the
end of training. As a result a simple to
use, colour coded CDD Competency
Checklist was developed to be used by
the trainers during training and also
during support supervision visits. The
checklist was organised to assess CDD
skills in the same integrated format as
the revised I CCM Training Manual.

observe CDDs’ skills and determine if

by the ICCM trainers during the clinical
session on the fifth day of training to
they are competent to deliver ICCM
in their community. CDDs need to
demonstrate a satisfactory or ‘OK’
level in all skill areas in order to get
a Certificate of Competence at the
end of the training and receive their
ICCM drugs. Those that do not meet a

The CDD Competency Checklist is also
used by Malaria Consortium field trainers
and CDD supervisors during support
supervision visits to assess how well
CDDs apply the skills they learned in
training and how much they improve
with practice. During the TOT, trainers
were trained on support supervision skills
including how to use the competency
checklist to coach and mentor CDDs
to improve their ICCM skills.

satisfactory level are given a Certificate
of Attendance but do not receive the
drugs. They are invited to attend the
full training again at a later time.

Result
The CDD Competency Checklist has been a useful tool at all levels of
implementation. The checklist has allowed Malaria Consortium’s project
and field officers to assess CDDs objectively and decide whether they
should be provided with drugs at the end of the training. By introducing
the tool early on in the training, the CDDs and communities ready to
accept decisions over whether or not a particular CDDs is competent.
The tool has also been useful for accountability to both donors and to
the MoH, who have previously expressed concerns about the ability of
volunteers to deliver such treatment. During the piloting process of the
revised manual staff from other organisations were invited to attend the
initial TOT. They were able to compare differences and similarities in the
methods of work and give feedback.
Malaria Consortium trainer shows CDDs the
contents of the ICCM drug box

[ 21 ]

Post-revision ICCM training
implementation
April 2012 onwards

The new package of training
was rolled out to

110 CDD
supervisors
and

655 CDDs
by June 2012

Once all revisions and reviews had been
completed and 10 additional Malaria
Consortium field officers recruited and
trained to be CDD trainers, the NBeG team
rolled out the new full package of ICCM
training to 111 CDD supervisors and 655 CDDs
by the end of June 2012.
Following the revision of all the training
materials, Malaria Consortium brought
together a number of stakeholders relating
to ICCM including implementing NGOs,
MoH staff and donors to present the revision
process that had been followed and to share
the new and revised materials. The training

materials were generally received very well
by the partners, some of whom are planning
to use them with some slight modifications.
In the absence of an updated and approved
set of training materials for ICCM in South
Sudan, Malaria Consortium is proposing
these materials form a foundation for review
and refining by other ICCM implementing
partners to move towards the production
of harmonised materials. The process of
harmonisation is expected to take place
within the next three to six months through
the technical leadership of IRC, supported
by funding from CIDA.

[ 22 ]

Lessons learnt
1 It is crucial to conduct continuous
evaluation of training and materials
through extensive piloting, field testing,
revision and re-testing to ensure that
training quality is continually improved
upon and that the materials work as
effectively as possible in different contexts.
2 It is important to assess a sick child
holistically. By the time children are seen
by CDDs, they may present with several
conditions. This was often confusing for
the CDDs who had undergone training
using the disease-by-disease method.
However, by aligning the training with
a routine health consultation, this
presented less of a barrier to CDDs.
3 Adult learning strategies start
from what people already know,
however, in the South Sudan context,
insight into the competencies of the
core trainers and the CDDs was gained
through implementation experience.
Particularly key for the review was a
focus on effective learning styles for
low-literacy settings.
4 Pictorial training worked very well.
Using this model adds an element
of equality to the group as it is less
significant whether members are literate
or not or which language they speak.
Pictorials also help trainers who do not
completely speak the language of the
CDDs to communicate key concepts.

5 Additional time within the training
needs to be dedicated to teaching the
new strategies and tools developed
to address low literacy and numeracy,
and to assessment of CDD skills at
using these tools. This can be achieved
through the use of a standardised and
objective checklist to determine the
CDDs’ qualification for the role and its
associated responsibilities.
6 The trainers found that the less
translation required within a training,
the better the flow of delivery and
learning. As a best practice from the
first phase, trainers worked in teams to
ensure that all language groups spoken
by the CDDs were covered. Where
there was a mixed language group,
the trainers often used a combination
of Arabic or support from the CDD
supervisor who had already been trained
in the content. The revised training
manual was written in simple English
with short sentences. The technical
content was simplified and included
in the trainer instructions. As a result,
trainers were able to easily translate it
into Dinka or Luo at the same time as
delivering the training.

8 It is important to involve the
MoH and other ICCM partners in the
development of materials and any
revisions to gain their buy-in to the
process and the products that result.
9 In planning the project’s activities,
including training implementation, the
initial work plans developed did not
account for all of the resources (technical
support, numbers of training teams,
logistics, procurement timelines etc.) that
were required to roll out the training.
This needed to be at a sufficient scale
to reconcile the heavy technical MoH
guidelines with very low levels of
literacy. In this situation, embedding
continuous learning and improvement is
critical and should be accommodated for
in work planning.
10 When considering, or monitoring,
any large project or programme, it is
important to step back and have a
‘helicopter view’ of what happened,
providing sufficient ways for people
to learn from each other, both within
organisations and between countries.

7 A glossary of terms / dictionary was
included in the original training materials,
and its importance was reiterated as
a best practice. After the mid-term
review, the glossary was updated to
include more words and meanings were
confirmed though back-translation.
Words in Dinka and Luo were also
added to the Sick Child Job Aid where
there were English words.

Child survival officer, Samuel Majek
shows how to use the armband test for
malnutrition in children under five years

[ 24 ]

About Malaria Consortium
Malaria Consortium is one of the world’s leading nonprofit organisations specialising in the comprehensive
control of malaria and other communicable diseases
– particularly those affecting children under five.
Malaria Consortium works in Africa and Southeast Asia
with communities, government and non-government
agencies, academic institutions, and local and
international organisations, to ensure good evidence
supports delivery of effective services.
Areas of expertise include disease prevention, diagnosis
and treatment; disease control and elimination; health
systems strengthening, research, monitoring and
evaluation, behaviour change communication, and
national and international advocacy.
An area of particular focus for the organisation is
community level healthcare delivery, particularly through
integrated case management. This is a community based
child survival strategy which aims to deliver life-saving
interventions for common childhood diseases where
access to health facilities and services are limited or
non-existent. It involves building capacity and support
for community level health workers to be able to
recognise, diagnose, treat and refer children under five
suffering from the three most common childhood killers:
pneumonia, diarrhoea and malaria. In South Sudan, this
also involves programmes to manage malnutrition.
Malaria Consortium also supports efforts to combat
neglected tropical diseases and is seeking to integrate
NTD management with initiatives for malaria and other
infectious diseases.
With 95 percent of Malaria Consortium staff working in
malaria endemic areas, the organisation’s local insight
and practical tools gives it the agility to respond to
critical challenges quickly and effectively. Supporters
include international donors, national governments and
foundations. In terms of its work, Malaria Consortium
focuses on areas with a high incidence of malaria and
communicable diseases for high impact among those
people most vulnerable to these diseases.
www.malariaconsortium.org

Malaria Consortium child survival officer, Samuel Majek

Malaria Consortium
Development House
56-64 Leonard Street
London EC2A 4LT
United Kingdom
Tel: +44 (0)20 7549 0210
Email: info@malariaconsortium.org
www.malariaconsortium.org

This material has been funded by UK aid from the UK Government,
however the views expressed do not necessarily reflect the UK Government’s official policies

Designed produced by
ACW, London, UK
www.acw.uk.com
October, 2012

Developing and implementing training materials for integrated community case management in South Sudan

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