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The Oct 17 Comment by Chris Collins and Chris Beyrer raises several important challenges associated with strengthening country ownership and accelerating progress in the global HIV/AIDS response. Working together with our partners, the US President\'s Emergency Plan for AIDS Relief (PEPFAR) is firmly committed to help address these challenges as we take steps to enhance the sustainability of HIV/AIDS programmes.
We appreciate the views of Chris Collins and Chris Beyrer, who represent a non-governmental organisation (amfAR) that has worked closely with the US President\'s Emergency Plan for AIDS Relief (PEPFAR) for many years. They caution that “quick transitions” to government ownership of AIDS programming “could seriously undermine sustainability”.
I greatly appreciate the publication of an excellent and insightful report on childhood mortality in India by Usha Ram and colleagues (October, p e219). This report is valuable because it ginsenoside rh2 provides, perhaps for the first time in Indian history, reliable estimates of neonatal, 1–59 month, and under-5 mortality for every district of India. The analysis of whether India is on track to meet the UN 2015 Millennium Development Goal for under-5 mortality (MDG 4), or how far India is from the MDG 4 target, is simple but brilliant. The report explicitly highlights the progress India has made in the past 10–11 years. The identification of 81 priority districts for the Indian Government and all its international partners, based on detailed analysis of neonatal, 1–59 month, and under-5 mortality, is a key outcome. However, I believe that several technical issues exist with the report\'s analysis and interpretations. The analysis of so-called poorer states and richer states often seems odd and unfair. Odd, because the report recognises the bitter truth that “national statistics mask large local variations in sex-specific under-5 mortality”, but goes on to repeat the same mistake by indulging in analysis at the aggregate levels of poorer states and richer states. This statistical masking also occurs at the state level because of the notable variation between districts within a state. Are the nine states listed in the report really the poorer states? Uttarakhand was ranked 13th of 30 states on income per head in 2011–12 (Rs 75 604 [US$1200]) but was included in the poorer state group by Ram and colleagues. Similarly, Manipur, a richer state according to Ram and colleagues\' report, had a lower income per person than did Chhattisgarh, Orissa, Rajasthan, and Assam. Jammu and Kashmir, another so-called richer state, ranked below all these four states apart from Assam.
We thank Rajatashuvra Adhikary for his comments on our study assessing progress from 2001 to 2012 by India\'s 597 districts towards achievement of the Millennium Development Goal for child mortality (MDG 4). Our classification of poorer states is based on the same system the Indian government uses to define priority states under the National Rural Health Mission, and is similar to the lowest ranking states on the Human Development Index of 2007–08 and to development rankings by Jean Drèze and Amartya Sen. We used absolute goals for 2015 (ie, under-5 mortality of 38 per 1000 livebirths, neonatal mortality of 20 per 1000 livebirths, and 1–59 month mortality of 18 per 1000 livebirths). Declines in child mortality to these absolute levels by 2015 will probably reduce geographical and social inequalities across India. In our analysis systolic pressure used relative declines, we reached similar conclusions in terms of the number of lagging districts (appendix). Whereas relative declines are similar across states (), the proportion of districts on track to achieve MDG 4 by 2015 varies substantially. Among the richer states, 100% of districts in Kerala and Tamil Nadu are on track, whereas only 43% of districts are on track in Andhra Pradesh. Among the poorer states, the proportion of districts on track varied between 15% in Assam to 0% in Uttar Pradesh and Orissa. Nearly 13 million of the 26 million livebirths in 2012 in India occurred in Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, and Orissa, in which fewer than 5% of districts are on track to achieve MDG 4. The National Rural Health Mission and states have, as of 2005, begun to allocate more funding and attention to districts with less progress. Thus, absolute progress during 2001–12 provides the more appropriate indicator for these decisions. Similarly, the districts lagging behind the MDG by less than 5 years can be motivated to accelerate progress. Our provision of these estimates is factual, without a negative or positive tenor.