Absolute and relative declines in child mortality in India's districts during 2001–12
Authors: Rajatashuvra Adhikary
Journal: The Lancet Global Health (2013)

I greatly appreciate the publication of an excellent and insightful report on childhood mortality in India by Usha Ram and colleagues (October, p e219).1Ram U Jha P Ram F et al.Neonatal, 1–59 month, and under-5 mortality in 597 Indian districts, 2001 to 2012: estimates from national demographic and mortality surveys.Lancet Glob Health. 2013; 1: e219-e226Summary Full Text Full Text PDF Scopus (87) Google Scholar This report is valuable because it 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])2Press Information BureauGovernment of IndiaPer capita net state domestic product at current prices.http://pib.nic.in/archieve/others/2012/mar/d2012032902.pdfGoogle Scholar 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.2Press Information BureauGovernment of IndiaPer capita net state domestic product at current prices.http://pib.nic.in/archieve/others/2012/mar/d2012032902.pdfGoogle Scholar Overall, although the achievements of the report are motivating and praiseworthy, the tone is mostly negative because it focuses on the failures too much. Why were Ram and colleagues silent with regard to the 153 districts that were only lagging behind MDG 4 by “up to 5 years”? In reality, many of those districts are just a little behind schedule and will probably achieve MDG 4 by 2015. The report mentions, “The absolute decline in under-5 mortality is an appropriate measure to reduce geographic (and to some extent social) inequalities”. This conclusion is not convincing. Do Ram and colleagues have enough evidence to support this conclusion? The report also comments, “Finally, all districts could benefit from better accountability and assessment of their performance”. A clarification of this statement would be useful. I declare that I have no conflicts of interest. Neonatal, 1–59 month, and under-5 mortality in 597 Indian districts, 2001 to 2012: estimates from national demographic and mortality surveysAt current rates of progress, MDG 4 will be met by India around 2020—by the richer states around 2015 and by the poorer states around 2023. Accelerated progress to reduce mortality during the neonatal period and at ages 1–59 months is needed in most Indian districts. Full-Text PDF Open AccessAbsolute and relative declines in child mortality in India's districts during 2001–12 – Authors' replyWe thank Rajatashuvra Adhikary for his comments on our study1 assessing progress from 2001 to 2012 by India's 597 districts towards achievement of the Millennium Development Goal for child mortality (MDG 4). Full-Text PDF Open Access