Ending the by mikeholy


        June 17 2002

    The pre – birth
Elimination of Females
        in India
 Ending the
 Changing the

A National Advocacy
                                                                                            Executive Summary

Provisional figures from the Census 2001 show that the sex ratio in the country which is adverse to females
(933f:1000m), is worsening rapidly in the youngest age groups. All indications are that this alarming trend is accounted
for by son desirous families, who with the help of unscrupulous medical practitioners and modem technology,
deliberately avert the birth of female children. Research evidence is limited, but some disturbing new findings have begun
to confirm the most pessimistic suspicions – a large proportion of abortions are sex selective. The pre-birth elimination of
females (PBEF) is not restricted to any particular group; it is a nationwide phenomenon. However, aggregate sex ratio
figures for states conceal the fact that there are very significant inter-district and inter-regional variations within states.
Research from other countries e.g. China, shows that sex imbalances in the population can result in dire social problems.
The Government of India is fully committed to gender equality and the principles of non-discrimination; it has a socially
just Constitution as has ratified major human, women and child rights‟ instruments, which condemn gender
discrimination and PBEF in no uncertain terms. The State thus has an official commitment to address PBEF.

In India, the origins of prenatal sex determination can be traced to the availability of amniocentesis in 1974. Soon after
this and other methods started being used for prenatal sex determination. Ultrasound scanning rapidly gained popularity in
the 80s and 90s as a non-invasive means of telling fetal sex. In 1988 as an outcome of intense lobbying Maharashtra
passed legislation to regulate the misuse of prenatal diagnostic techniques and in 1994 the Prenatal Diagnostic
Techniques (Regulation and Prevention of Misuse) Act (PNDT Act) was enacted at the central level. The enforcement of
the Act was not effective; as a result sex determination (especially with the help of ultrasound scans) and PBEF continued
through the „90s. In February 2002, public interest litigation with respect to the non-enforcement of the law was filed in
the Supreme Court. Following the directives of the Supreme Court a number of actions have been taken by the Ministry
of Health and Family Welfare to implement the PNDT Act and to amend it. Several agencies, governmental and non-
governmental have initiated measures to create public awareness about the Act as well as the causes and implications of
sex selection.

While many have been innovative and creative, in general advocacy and communication measures have been scattered.
Approaches and target groups have been varied. The absence of research before conducting communication activities has
limited the possibility of assessing their validity. And minimal documentation after their conclusion has meant that
learning‟s, both positive and negative, have gone inadequately shared. As a result effects have been heterogeneous and
not necessarily additive. This National Advocacy Strategy (NAS), which builds upon past and existing advocacy and
communication activities, provides an umbrella framework within which to plan and implement forthcoming initiatives.
The purpose of providing a common national framework is to ensure that advocacy and behavior change interventions,
undertaken by and with different groups are synergistic, coordinated, and non-contradictor. It is expected that a common
vision and approach will not only result in the better utilization of limited resources, but also lead to outcomes which are
multiplicative in effect and which will contribute to reversing the adverse trend in the sex ratio.

The NAS specified the current situation as one where sex ratios are declining at an alarming rate, where sex determination
technology and services (though underground) continue to be available, and where the demand for these services cuts
across all social and geographic divisions and continues unabated, intensified in many cases by the small family norm. To
address this situation, the NAS recommends the synergistic use of three strategic components: advocacy, social
mobilization and behavior change communication. It also recommends systematic and rigorous planning which
incorporates five key stages: analysis, strategic design, development of communication tools, implementation, and impact
evaluation. The need for flexibility and the capability of adjusting to emerging issues and concerns is also recognized.

The NAS is firmly grounded in scientific principles of behavior change and emphasized the need for systematic research
ad analysis. It recommends that the most effective way to change behavior is to first identify the desired response and
then to design appropriate “stimuli” to trigger it. It recognizes the importance of building on experience; of understanding
the mindset of target audiences; of selecting audience appropriate media channels; of the culturally sensitive and creative
treatment of communication items; and, of the active participation of target audiences in creating them. Finally, the NAS
underlines the fact that the effectiveness of advocacy and communication is enhanced manifold if they are matched by
actual actions of the ground.

The NAS identified key stakeholder groups with respect to PBEF. These are i) the service recipient; ii) the immediate
motivators (those who motivate the immediate recipient; iii) service providers; iv) social catalysts (comprising NGOs,
medical bodies, researchers, journalists and other groups who can influence policy and public opinion); and, v) policy and
law makers, implementers and enforcers, As a sample it provides a detailed analysis of one group – service providers –
with respect to their awareness levels, attitudes, actions, internal motivations, external enabling factors, size of target
group, likelihood of the success of interventions with them and so on. The NAS recommends that similar analyses,
preferably after appropriate research has been conducted, be done with each of the stakeholder groups before undertaking
communication activities with them. At the same time it cautions that, while we await the results of research (which must
necessarily be conducted), some activities may have to start right away, given the urgency of the situation. Fortunately,
for the time being efforts can be guided by the insights of experts and available information.

Next the NAS goes on to recommend the heart of the national strategy. In view of the falling sex ratio there is little time
to lose and the non-availability/accessibility of prenatal diagnostic techniques for sex determination is likely to have a
significant effect on reversing the trend. The NAS recommends that closing down availability and accessibility through
changing the behavior of service providers (supplemented by appropriate and effective law enforcement) should be a key
line of action of “track.” Creating widespread awareness of the macro-and micro-level consequences of PBEF through
activating and enriching the resources and skills of various groups of social catalysts and enabling them to influence all
other stakeholders is recommended as the second track of activity. The future vision articulated in the NAS is a situation
where boys and girls are equally valued and there is neither demand nor supply with respect to sex determination
techniques. It is recognized that to arrive at such a situation requires both time and the combined resources of different
agents and sectors. No distinct activities are recommended for this third track; however, all the Track I and Track II
activities of the NAS will be directly linked to, cognizant of and contribute toe the desired long-term outcomes. Also
efforts to incorporate and mainstream the need to end PBEF in all advocacy and communication opportunities in other
sectors are seen as also constituting Track III efforts. Advocacy and communication activities with identified, multiple
stakeholders will take place concurrently along all three tracks.

The NAS concludes by recommending that specific action plans should be developed at the national and sub-national
levels. The where and how of materials development is specified. Research and documentation needs are broadly
identified. The importance of monitoring is underlined. It is suggested that a specific institutional mechanism be set up to
operationalize the strategy and that this mechanism must incorporate expertise from the fields of gender, medicine, law,
communication and the media; additionally it should have representation from both the government and non-government
sectors. The NAS ends with a list of next steps.
Part I
   1.     The Need for a National Advocacy Strategy
   2.     India’s Declining Sex Ratio
   3.     The Effects of Sex Imbalances in the Population
   4.     The Nation’s Commitments
   5.     Origins and Spread of Prenatal Sex Determination
   6.     Prenatal Sex Determination and the Law
   7.     The PNDT Act: enforcement and effectiveness
   8.     A Turning Point
   9.     Institutional Arrangements, Advocacy and Communication

Part II
The Advocacy Strategy
   10.    What Must Be Done
   11.    What a National Advocacy Strategy Can Aim to Achieve
   12.    Changing People’s Behavior
   13.    Potential Target Audiences and Allies
   14.    Mapping Mindsets, Information Needs and Routes to Changing Behavior
   15.    The Advocacy Strategy
   16.    Development, pre-testing and production of materials
   17.    Research and Documentation Needs
   18.    Monitoring
   19.    Operationalizing the Strategy
   20.    Next Steps
                                                                              June 17 2002

                    The Pre-birth Elimination Of Females

                                               Part I
1.   The Need for a National Advocacy Strategy
     India is no the brink of a demographic catastrophe. If effective measures are not taken
     immediately boys and men will soon vastly outnumber girls and woman. There are already
     some parts of the country where in some age groups there are less than 800 females for every
     1000 males. 1 Such a sex composition in the population is likely to bring on social calamities
     which are as yet unimagined.

     While diminishing steadily in the preceding decades of the last century the sex ratio for the
     country as a whole improved in the decade of the `90s; however at 933 females to 1000 males
     it continues to be significantly adverse to women. As if this is not worrying enough the
     decline in sex ratio, particularly in the youngest age groups has accelerated in the last decade.
     All indications are that this alarming trend is on account of families, who with the help of
     unscrupulous medical practitioners and modern technology are deliberately averting the birth
     of female children. The loss of so many female lives constitutes nothing short of a silent and
     insidious national tragedy.

     In India, pre-natal sex determination is a culpable offence but the enforcement of the law,
     which has been in place since the mid-nineties, has been negligible. Over the last twenty-five
     years, some groups of vigilant and concerned activists and professionals have made
     committed advocacy and communication efforts-to create awareness about the law, to lobby
     for its enforcement, and to provide evidence of violations. In general, the various actions have
     been limited in scale, and because they have been scattered and isolated their impact has not
     always been additive.

     While considerable success has been achieved in drawing attention to the issue of the pre-
     birth elimination of females (PBEF) as well as its causes and consequences, the sex ratio
     among many groups has been continuing on a relentless downslide.

     Cognizant of the fact that there is no time to lese, the Government of India has developed this
     National Advocacy Strategy (NAS) in order to articulate a common framework within which
     to animate a series of immediate and sustained advocacy and communication interventions.
     The purpose of providing a common national framework is to ensure that advocacy and
     behavior change interventions, undertaken by and with different groups are synergistic,
     coordinated, and non-contradictory. This will likely ensure that results are multiplicative and
     demonstrate their impact by reining in the galloping decline in sex ratio in the coming years.
     The Strategy is based on the premise that if such a goal is to be achieved effectively and
     within a definable time frame, hard and focused choices will have to be made with respect to
     the direction and content of all efforts.
     Building on available experience and based on a detailed problem analysis, the Strategy
     recognized that discrimination against females even before they are born, can only be
     addressed effectively if root causes are addressed and fundamental transformations take place
     in gender relations and patriarchal institutional formations. The Strategy also recognizes that
     it will be several decades before such changes and be accomplished. The Strategy
     recommends simultaneous progress on the three tracks: immediate measures to control the
     practice of eliminating females before birth; the creation of widespread awareness in the
     medium term of the implications of PBEF; and term. Progress on each track will take place
     through the engagement of multiple stakeholders and multiple media channels.

     Ultimately, all social progress, be it lobbying for social legislation or sending girls to school,
     or enabling women to participate in the public sphere, occurs because of the changed behavior
     of individuals and groups. Keeping this in view, the Strategy, which is grounded in scientific
     principles of behavior change, identifies critical groups whose behavior must change and
     recommends how this can be achieved. It is acknowledged that no strategy can anticipate the
     entire range of future challenges; in view of this the Strategy allows for flexibility to respond
     and accommodate to newer questions and concerns as they arise.

2.   India’s Declining Sex Ratio
     Excessive female mortality, particularly in childhood, is a grave indictment of “son
     preference” cultural norms and perceptions that defeat the biological head start with which the
     female is naturally endowed. It is one of the worst forms of violence against women and a
     symptom of the discrimination – social, cultural and political – that continues throughout the
     life cycle of a woman. On account of her gender a girl child is typically denied health care and
     education and exploited economically. While the situation is changing very gradually, as an
     adult the average woman has low status is excluded from the public sphere and is denied the
     right to exercise influence with respect to society, family decision-making and even her own
     body. Women are viewed as a liability because they are seen to need protection and because
     the benefits of investing in them accrue to the families into which they are married. These
     factors along with a plethora of cultural and religious beliefs constitute the root causes for
     why sons are preferred and why daughters are not desired.

     Census data show a consistent drop in the sex ratio from 1901 to the year 2001 (see Figure 1).
     The decline in the number of females has typically been explained by higher death rates
     among them due to high maternal mortality, neglect of girls‟ health care needs resulting in
     higher mortality among them, female infanticide, and male bias in the enumeration of the
     population. Observing the availability and utilization of sex determination services in the
     `80s, as well as the even further reduced number of females in the Census data for 1991, alert
     health activists added another explanatory factor: female feticide. 2

     There are considerable variations in the overall female to male sex ration from one state to
     another. The only state in which the overall sex ratio is above 1000 is Kerala (with a figure of
     1032 in 1991). The states of Karnataka, Tamil Nadu, Andhra Pradesh, Orissa, Jammu and
     Kashmir and Himachal Pradesh have and overall sex ratio between 950-1000. Provisional
     census data have shown a slight improvement in the national sex ratio; it has increased from
     927 in 1991 to 933 in 2001. But this seemingly good news has been accompanied by the
     alarming finding that the sex ratio in the 0-6 years age group has declined to unprecedented
     levels in several sates (see Figure 2).

     The intensity of the sex ratio imbalance in the 0-6 age group is most striking in, though not
     limited to, affluent regions of Punjab (793), Haryana (820), Chandigarh (845, Gujarat (878),
     Himachal Pradesh (897) and Delhi (865). Under normal conditions the sex ration in this age
     group should be 1000.

     No conclusion has been reached with respect to the relative contribution to the declining sex
     ratio of the various identified factors. Research on female infanticide in the „80s and „90s
     showed that it was more widespread than believed earlier and that is was almost a “cultural
     tradition” in some communities (e.g. warrior groups in Rajashtan). Research also showed that
     the practice was limited to relatively identifiable pockets of the population (e.g. communities
     in Bihar, Punjab, Tamil Nadu and Rajasthan). For the general population however, the desire
     for sons had not translated itself into the killing of daughters. But with the availability of sex
     determination technology son desperate families were afforded a “sanitized” means to rid
     themselves of daughters and rapidly gained popularity among and groups. With the
     promotion3 and adoption of the two-child norm the desire for at least one son seems to have
     become “intensified” and more and more families are seeking (and being encouraged to seek)
     PBEF services. The unprecedented and accelerating and nationwide fall in the number of
     females in the youngest age groups, experts agree cannot be explained only in terms of
     infanticide or early childhood neglect. In their view it is closely linked to declining sex ratio at
     birth resulting from PBEF, which in turn has increased because of the misuse of modern
     medical technology. This is confirmed by the fact that in very remote areas of the country
     (e.g. some tribal tracts), where sex determination services are not available, male mortality in
     the younger age groups is higher and the sex ratio is not adverse to females. This pattern is in
     line with expected biological patterns,

     While in the early `80s, families with 3-4 daughters, sought out sex determination services to
     ensure the birth of a son, more recently families are going in for such services for even the
     first pregnancy. Research evidence is limited, but some disturbing new findings have begun to
     confirm the most pessimistic suspicions. Recently, a study estimated that in Haryana and
     Punjab (1996-98), sex selective abortions accounted for 81 and 26 per cent of total induced
     abortions respectively.4 Similarly, the preliminary results of a study from Bombay show that
     10 per cent of a sample of women who had undergone abortions said they has done so to
     remove female fetuses; 4 per cent said if the baby has been born they would have killed it.5

     Aggregate sex ratio figures for states conceal the fact that there are very significant inter-
     district and inter-regional variations within states. For instance, research shows that in Punjab
     and Haryana, which show the highest preference for sons, the practice of PBEF appears to be
     more widespread in urban as compared to rural areas (e.g. Orissa). Whereas a detailed
     analysis of these variations is beyond the scope of the present document, it is important to
     note that to be responsive to the situation on the ground, the Strategy will have to take into
     account the heterogeneous situation both between and within sates.

3.   The Effects of Sex Imbalances in the Population
     Son preference norms and high rates of sex selective abortions exist in many Asian societies.
     Notable among these are China, South Korea and Taiwan. In China the sex ratio at birth
     moved from 106 males per 100 females in the `60s and `70s to 111.9 in early 1990.6 China
     has begun to show some of the grim outcomes of the skewed sex composition of the
     population. The findings are countered intuitive: fewer surviving women do not mean that
     they enjoy a higher status. On the contrary the growing shortage of women in the marriage
     market means that they are subjected to being kidnapped by criminal gangs and sold into
     marriage to men anxious to find wives. In the year 2000 alone, more than 19 000 perpetrators
     of women and child trafficking were arrested. The situation is serious enough for the Chinese
     government to have passed decrees in 1991 and in 2000 to crack down on these criminals, for
     women‟s magazines and some provincial governmental organizations to publish advice on
     how to avoid being kidnapped, and for some public security departments to set up hotlines for
     reporting such crimes. Trafficking in women is likely to increase, as the squeeze in the
     marriage market becomes more pronounced.8

     It is not far fetched for us in India, particularly in some pockets of the country, to expect a
     similar situation, and other situations that may be even worse, if sex ratios continue to decline.
     It is important to note that the compounding effect of PBEF on the country‟s already declining
     sex ratio is not merely a “girl child problem” or one that needs to be addressed by the health
     community alone. It could result in a demographic and social disaster, which if it is to be
     prevented needs the wisdom and resources of a variety of sectors and groups and these are
     needed urgently.

4.   The Nation’s Commitments
     The Government of India is fully committed to gender equality and the principles of non-
     discrimination. These are amply articulated in India‟s liberal Constitution, Directive
     Principles of State Policy and progressive social legislation.

     In addition to several other human rights instruments, the Government of India has ratified the
     Convention on the Rights of the Child (CRC) and the Convention on the Elimination of All
     Forms of Discrimination Against Women (CEDAW). Both these instruments reaffirm the
     non-negotiable commitment to girls‟ and women‟s human rights, particularly their right to life
     and the State‟s obligation to protect it India is also a signatory to the Programme of Action
     that emerged from the International Conference on Population and Development (Cairo,
     1994) and the Platform for Action that was developed at the Fourth World Conference on
     Women: Action for Equality, Peace and Development (Beijing, 1995). Each of these
     documents discusses pre-natal sex selection specifically and obliges governments to take
     immediate and appropriate actions to stop the practice. One of the expressions of gender-
     based discrimination, these documents assert is the selective elimination of females even
     before they are born; this is unacceptable and as women‟s rights to survival and equality are
     The National Population Policy 2000 (NPP 2000) acknowledges the practice of female
     feticide as contributing to the deficit of females in the country. While it does not specify any
     strategies to control the practice, NPP 2000 provides for promotional and motivational
     measures for the adoption of the small family norm and within it to promote the survival and
     care of the girl child through case incentives.

5.   Origins and Spread of Pre-natal Sex Determination
     In India, amniocentesis and its abuse can be traced back to 1974. Originally, developed as a
     technique to diagnose chromosomal abnormalities by analyzing amniotic fluid, amniocentesis
     and other procedures such as chorionic villi biopsy (CVB) were soon utilized to “diagnose”
     females who could subsequently be aborted. By 1979, there was a ban on sex determinations
     in all government institutions. At the same time private clinics performing sex determination
     tests and procedures, the first one in Amritsar, started emerging and spreading all over
     Northern and Western India. Ultra-sound machines became available in the early „80s and
     were used by these clinics to detect fetal sex. This non-invasive and instant sex determination
     method gained considerable popularity. In the `80s and `90s clinics (particularly in Punjab,
     Haryana and Bombay) advertised blatantly; playing deviously on the sentiment of free choice
     a common slogan on billboards and in newspapers was; “Boy or girl? You can choose.”
     Advertising was matched with service “at-your-doorstep”; enterprising health service
     providers took mobile ultra-sound machines into the remotest villages. In Punjab, the under-5
     years sex ratio fell from 925 to 874 between 1981 and 1991. Sharp declines also occurred in
     Haryana and Rajasthan. All over the country thousands of female fetuses were aborted. And
     millions of families become aware for the fist time of the possibility of choosing the sex of
     their offspring.

6.   Pre-natal Sex Determination and the Law
     In 1988, as an outcome of intense lobbying by health activists and professionals, the state of
     Maharashtra became the first in the country to ban pre-natal sex determination through the
     enactment of the Maharashtra Regulation of Pre-natal Diagnostics Techniques Act. Similar
     efforts at the national level resulted in the enactment of the central Pre-natal Diagnostic
     Techniques (Regulation and Prevention of Misuse) Act (PNDT Act) on September 20, 1994.
     The law came into operation on January 1, 1996. Rules were framed under the Act in 1996
     and 1998. One immediate effect of the law was that blatant advertising came to a halt.

     The Act provides for the “regulation of the use of prenatal diagnostic techniques for the
     purpose of detecting genetic or metabolic disorders, chromosomal abnormalities or certain
     congenital malformations or sex-linked disorders and for the prevention of misuse of such
     techniques for the purpose of prenatal sex determination leading to female foeticide and for
     matters connected therewith or incidental thereto.” Except under certain specific conditions,
     no individual or genetic counseling center or genetic laboratory or genetic clinic shall conduct
     or allow the conduct in its facility of, pre-natal diagnostic techniques including ultra-
     sonography for the purpose of determining the sex of the fetus; and “no person conducting
     prenatal diagnostic procedures shall communicate to the pregnant women concerned or her
     relatives the sex of the foetus by words, signs or in any other manner.” The Act provides for
     the constitution of a Central Supervisory Board (whose function is mainly advisory) and for
     the appointment of an Appropriate Authorities (AAs) in States and Union Territories (to
     enforce the law and penalize defaulters) and Advisory Committee’s (ACs) to aid and advise
     the AAs.

7.   The PNDT Act: enforcement and effectiveness
     In India, the policy environment is supportive of the reproductive choices of women and men.
     The medical termination of pregnancy is legal. The Medical Termination of Pregnancy Act
     (1971) allows for induced abortion in instances where pregnancy carries the risk of grave
     injury to a women‟s physical and/or mental health, endangers her life or when it is a result of
     contraceptive failure or rape. A negative outcome of the PNDT Act, as in the case of most
     such legislation, was that the practice of sex determination was driven underground. Word of
     mouth communication continued nonetheless and the availability of services proliferated
     correspondingly. Ultra-sound machines continued to be widely available and simple to use;
     other technologies for pre-conception and pre-natal sex determination were also available. In
     such an environment it was, to say the least. Very difficult, to enforce a law which sought to
     control information that travels through informal channels or to control the behavior of
     individuals who have a right to privacy and can operate in secrecy. Essentially. What needed
     to be controlled was the transmission of information from the ultra-sonologist (or other
     technical person capable of detecting the sex of the unborn child) to the family. It has been
     asked. Pertinently, How is it possible to control information that can be conveyed through a
     mere smile or frown on a doctor‟s face! Unsurprisingly the enforcement of the law was weak.
     Other reasons forwarded for the limited effectiveness of the law include: lack of political will
     – to ensure enforcement: lack of enforcement – all over the country authorities have not
     insisted on compulsory registration or taken penal action against unregistered facilities; and
     social indifference – on the whole NGOs, civil society organizations, activists and society at
     large have not given this issue the necessary attention that it deserves.

     Experience ahs shown that in general the role of legislation in subverting a social practice is
     limited. The example of legislation against child marriage and dowry is often cited in this
     respect. Everybody agrees that addressing the root cause of a social issue is the only sure way
     to bring about social change. It is also agreed that these root causes are the most resistant to
     change. At the same time is acknowledged that legislation has an important role to play. It
     articulates the position of the State and it places in the hands of social actors a tool with which
     they can leverage change. It can create a space within which awareness creation and action
     against culprits is possible. Some believe that the focus on why the law cannot be enforced
     has clouded our ability to assess what can be done.

8.   A Turning Point
     The ineffectiveness of the law and the unabated continuation of prenatal sex determination
     and sex selective abortions galvanized alarmed health activists to take action and lobby for
     enforcement in the years after the PNDT Act came into force. In response, some medical
     practitioners filed petitions in court questioning the constitutionality of the PNDT Act. And
     they encouraged their peers to do the same. In view of the opposition to the legislation as well
     as the deteriorating situation, in February 2002, a public interest litigation (PIL) was field in
     the Supreme Court by concerned health activists, In response to the petition, the Court issued,
     in May 2000, notices to the Central and State Governments to file replies Central
     Government, the Central Supervisory Board, State Governments/UT Administrations and,
     among other things, to appoint an AAs at district and sub district levels, and to appoint ACs.
     Directions stated that the list members appointed. should be published in the print and
     electronic media. AAs were further directed to send a quarterly report to the Central
     Supervisory Board. Public awareness against the practice of pre-natal sex determination was
     also to be created. The petition came up for hearing most recently on April 30, 2002, when the
     Supreme Court directed State Governments to take further steps to enforce the law and the
     Secretary. Department of Family Welfare was directed to file an affidavit indicating the status
     of actions taken.

     The Supreme Court in its order dated December 11, 2001 directed 9 companies to supply the
     information of the machines sold to various clinics in the last 5 years. Details of about 11 200
     machines from all these companies and fed into a common database. Addresses received from
     the manufacturers were also sent to concerned States and UTs to lunch prosecution against
     those bodies using ultrasound machines that had filed to get themselves registered under the
     Act. The Court in its order dated January 9, 2002 directed that ultrasound machines/scanners
     be sealed and seized if they were being used without registration. Three associations viz. the
     Indian Medical Association (IMA), Indian Radiologists Association (IRA) and the Federation
     of Obstetricians and Gynecologists Societies of India (FOGSI) were asked to furnish details
     of members using these machines.

     Since the Supreme Court directive of 2001 to date (May 31, 2002), 299 cases were registered
     and in 232 cases ultrasound machines, other equipment and records were seized. Today there
     are an estimated 25 000 ultra-sound machines in the country, of these 15 900 have been
     registered. State governments have communicated to the Central Government in writing the
     according to official reports received, they are satisfied that sex determination services are no
     longer being provided in their respective states. However. it is widely believed that while
     these services are no longer openly available, their clandestine availability and utilization
     continues all over the country. The observations of the National Inspection and Monitoring
     Commission confirm this situation 9 and endorse the need for stricter enforcement of the law
     as well as the need for a national advocacy and communication effort to address it.

     The Ministry of Health and Family Welfare (MOHFW) has proposed a series of detailed
     amendments to the 1994 Act; these are pending Parliamentary approval, which is imminent,
     These amendments relate mainly to expanded definitions e.g. “pre-natal diagnostic
     techniques” has been expanded to include pre-conception techniques, additions and more
     detailed explanations of sections contained in the Act. Fines of up to Rs. 100 000 can be made
     and a medical practitioner faces the liability of cancellation of registration for violation of
     violation of provisions. The amendments also build in checks and balances into the Act to
     control dereliction of duty by appointed individuals and bodies e.g. it recommended that the
     Government of each State will constitute a State Supervisory Board who will create public
     awareness, review the activities of AAs, monitor and review implementation, and submit
     consolidated reports to the center.

9.   Institutional Arrangements, Advocacy and Communication
     Given the worrying trend confirmed by the provisional census data as well as the renewed
     focus on sex selective abortions contingent on the Supreme Court‟s orders, MOHFW as well
     as well as a number of development and rights‟ organizations have intensified their efforts in
     recent months. The MOHFW has undertaken several very concerted actions.

                   The Central Supervisory Board (CSB) was constituted under the Chairmanship
                    of the Minister of Health and Family Welfare, to review and monitor the
                    progress of the PNDT Act. The CSB is required to meet once in 6 months.

                   Appropriate Authorities (AAs) and Advisory Committees (ACs) have been
                    constituted in all States and UTs at State/UT and district levels. These statutory
                    bodies have also been set up at sub-district levels in most of the major states.

                   A meeting of AAs on June 30, 2001, was facilitated to review and monitor the
                    implementation of the Act at the grassroots level; they were sensitized about
                    their role in implementing the provisions of the Act.

                   The CBS has constituted two sub-committees viz. i) the Technical Sub-
                    committee for considering amendments to the PNDT Act keeping in view the
                    emerging technologies and difficulties experienced in its implementation, and
                    ii) she Sub-committee on Implementation Strategy for implementing the Act.
                    Both Sub-committees had already met three times before December 2001.

                   The CSB has also constituted two groups – one to consider research proposals
                    (3 proposals have been recommended) and the second to consider proposals for
                    films, TV spots etc. (35 proposals have been submitted.)

                   MOHFW has circulated draft amendments to the PNDT Act to various
                    Ministries and Departments of the Central Government. A draft note for the
               Cabinet to amend the Act is under consideration of the Legislative Department,
               Ministry of Law.

              The PNDT Rules, 1996 are also being amended.

              A National Inspection and Monitoring Committee was set up on 3rd December,
               2001 to keep a constant watch on all States and UTs for implementation of the
               PNDT Act and compliance to the directions of the Supreme Court.

              The Union Minister for Health issued an appeal to all members of professional
               associations such as IMA and FOGSI to help in the enforcement of the Act.

              Regular meetings are held by the Partnership and Networking for Female
               Foeticide, which has been set up at the national level under the chairmanship
               of the Secretary, Department of Family Welfare.

Secretaries in all the States/UTs have been instructed that 50 per cent of IEC funds should be
spent on publicity activities with respect to the PNDT Act. Workshops and seminars are being
organized at the State/regional/district/block levels to create awareness about the provisions of
the Act; the Government has also approved project proposals submitted by a large number of
NGOs including the VHAI, SMANVAY, FPAI, REDS, and others. MOHFW has undertaken
several IEC activities. These include: awareness creation through government media units
(radio, TV and so on; various stations of AIR are broadcasting spots, group discussions and
talks on the PNDT Act in various languages; films on the subject of female feticide are being
telecast on the national channel); the Minister of HFW has addressed a letter to 200 000
doctors all over the country requesting them to extend their help and cooperate for the
eradication of the evil of female feticide.

UN bodies, such as UNFPA, UNICEF, WHO, have been working in close cooperation with
the MOHFW. Directly or through partners, these agencies have mobilized resources to build
media interest and concern, create networks, sensitize the health the health system, train
partners, conduct research, support civil society groups, and develop training and advocacy
material, UNFPA has played an important role in coordinating activities to address the issue
through commissioning research studies, hosting brain storming sessions and facilitating the
development of this national advocacy and communication strategy.

As a result of concerted efforts advertisements against PBEF in the print media have appeared
in about 250 national, regional and local language newspapers. A large number of newspaper
articles have been published on the subject, including 74 articles in the month after the
Supreme Court directive. An advertisement in the mass media directed clinics to display
prominently that no sex determination of the fetus is permissible or practices in their clinics.
Wide publicity has been given to the law though hoardings and wall paintings at the district
and sub-district levels. Posters on the consequences of practicing, aiding and abetting sex
selective abortions have also been made in a series of books entitled The Assignment. Two
films have been made – Atamaja and God’s Left Hand – in order to raise public awareness. In
Punjab, padyatras have been undertaken. The Punjab Health Systems Corporation (PHSC)
has engaged the services of a professional development communications agency to develop
suitable to develop specific public awareness campaigns.

In the non-government sector, advocacy and communication have had an important role to
play in awareness raising and action to control PBEF for the last 25 years or so. In 1986, the
Forum Against Sex Determination and Sex Pre-selection, a grouping of rights‟ and health
activists, had launched a campaign in Maharashtra. As a result of this, widespread occurrence
of sex selective abortions was accepted by the state and society as an issue of concern, the
Maharashtra law was enacted, the issue was brought into focus from the local to international
levels and debates were initiated on various aspects of the issue. In Tamil Nadu, the Society
for Integrated Rural Development initiated a campaign against sex selective abortions soon
after its state level consultation in 1998. This led to a creating public awareness about the
issue, the law and to the registration of hundreds of ultra-sound machines.

International NGOs such as Plan International have, with the assistance of local NGO
partners conducted advocacy efforts in states with elected officials, the media, medical
professionals, and civil society coalitions and alliances. CARE-India has been working on
mainstreaming the issue in all its existing projects and creating awareness among the general
population and particular groups such as local government bodies and traditional birth
attendants. The National Foundation of India has funded the efforts of journalists and
researchers alongside their more generic support to NGOs working for gender equity and
social justice. Most of these and similar agencies have joined hands with UN bodies to
advocate for the speedy passage of the PNDT Amendment Bill.

A number of NGOs all over the country, such as Vimochana (Bangalore/Karnataka),
CHETNA (Ahmedabad/Gujarat) and Vatsalya (Lucknow/Uttar Pradesh), have responded with
commitment and concern to the question of PBEF. For example, CHETNA, in collaboration
with the National Commission for Women, conducted a workshop for NGOs from Gujarat in
2001, to review the situation in the state and define their role. The Voluntary Health
Association of India (VHAI), state VHAs, the IMA and several other organizations have also
conducted workshops and seminars. VHAI has designed and printed posters (in Hindi,
English, Gujarati and Punjabi) on the consequences of practicing, aiding and abetting in sex
selection. The IMA in collaboration with UNICEF and NCW hel a meeting of religious
leaders was organized in July 2001 and female feticide was widely condemned and a pledge
was taken to stop it. The Akal Takth issued a hokum nama to the Sikh community to stop the

Private groups have also been participating in advocacy and communication efforts e.g. a
website indiafemalefoeticide.com has been launched on the Internet by Datamationindia as a
voluntary effort. This site houses a database of information on ultrasound machines in the
country as well as addresses of AAs. In line with the principles of e-governance, the site
provides the facility to lodge complaints under the PNDT Act and these are automatically
communicated to the concerned authorities. The site will soon start web casting jingles and
films on the subject. Other organizations that have been involved with the issue also provide
coverage on it in their home websites. A Google search on the Internet returns over 2500
results containing the words “India+female+foeticide.” The contents of these sites range from
newspaper articles to discussion papers.

Lessons Learnt: The efforts of various actors have led to the development of a growing body
of knowledge. An impressive list of needs and further steps to control sex selection has been
identified. Among efforts that need to be intensified are mainstreaming the issue, sensitizing
and motivating health professionals, working with medical bodies, involving local
government bodies and law enforcers such as the police, prosecuting and penalizing
offenders, conducting research, planning media campaigns, developing alliances and
coalitions, increasing press coverage, mobilizing volunteers, gaining public support,
amending and creating awareness of the law…the list goes on.
Workshop proceedings have been documented routinely. These are a rich source of
information. However, there is very little documentation about advocacy and awareness
raising efforts that have taken place. As a result, other than those directly involved in
particular efforts, few others know the successes and dilemmas of mobilizing against PBEF.
Experiences cannot be built upon and this could mean reinventing the wheel. One exception is
the Maharashtra experience from 1986. It had many lessons to offer and these have been
documented. 10 The Maharashtra experience showed that as a result of the campaign sex
determination clinics in Bombay went down in number and the practice of sex determination
lessened. This was the outcome of a sustained campaign and active monitoring of the Act by
FASDSP. However, once the campaign faltered, sex determination clinics resumed practice.
Retrospective observations about the campaign were that it had been unable to sustain its
momentum, that it had not meshed                        Learnings from Past and Ongoing
adequately with other debates relating to             Advocacy and Communication Efforts
reproductive rights and larger              Identified needs
developmental questions, that it had not       Need to mainstream issues
triggered critical research in areas such      Need to mesh with other debates on reproductive
as policy studies and demographic               rights
                                               Need to work with health professionals, medical
analyses, and that it was too centered on       bodies, local government and law enforcers
the “law/no law debate.” According to          Need for further research, planning media
the campaigners, future efforts should          campaigns, developing alliances and coalitions
build on existing experience and are           Need to create widespread awareness of the law,
likely to be aided by the emergence of          involve volunteers, increase press coverage
newer thinking on women‟s                   Lessons
reproductive rights and the availability       Lack of documentation results in inability to share
of new models of communication.                 learning and best practices
                                                 Campaigns can control PBEF; but the faltering of
Until recently, most agencies working             campaigns leads to a resurgence
                                                 Relative isolation of efforts and heterogeneity of
on PBEF while receiving some informal             approaches does not allow for an additive effect
guidance have been working in relative           The lack of involvement of gender and
isolation, and depending on their own             communication professionals in designing and
resources and skills to develop advocacy          monitoring A & C efforts diminish effectiveness
and communication interventions and              Validity of materials can only be ensured through
                                                  formative research and pre-and post-testing of
materials. This has possibly resulted in a        materials
great deal of heterogeneity of
approaches and contents. In the absence
of documentation it is difficult to gauge the nature or scale of this heterogeneity. Working on
a number of sub-issues in a number of different ways is not likely to produce visible impact
and usually implies underutilization of comparative advantage and wastage of resources.

Materials (including print, audio-visual and web sites) that have been prepared have not
always involved the skills or guidance of gender and/or communication professionals nor
been subjected to rigorous pre-, interim and post-tests. While the materials may “appear”
good it is unknown whether they achieved what they were intended to achieve e.g. changes in
attitudes. The lack of gender auditing has sometimes meant that while efforts to prevent sex
selection may be well intentioned, they may at the same time be antithetical to women‟s rights
(e.g. painting out the mother-in-law, rather than patriarchal attitudes, as the “villain.”)
Lastly, it is not known to what extent, representatives of target groups were involved in the
preparation of information and education tools. In the absence of such participation it is likely
that the insights and “real” concerns of particular groups go unaddressed making materials
less effective and again, wasteful of resources.
                                                 Part II
                               The Advocacy Strategy

10.   What Must be Done?
      Advocacy and communication are a very important part of what needs to be done to protect
      the birth of females and to correct the sex ratio in the country. The advocacy strategy for
      ending the practice of PBEF will depend on the synergistic use of three strategic
      components with respect to different clusters of messages (e.g. those pertaining to the law;
      those pertaining to gender equality; and so on):

                   Advocacy acts as a stimulant; in the case of PBEF it will act to ensure political
                    leadership and social commitment; to ensure that the amended law is in place;
                    to ensure that it is enforced effectively.

                    [Advocacy activities will be conducted with Group Five stakeholders identified
                    below, including parliamentarians and legislators social policy and decision
                    makers law enforcers)]

                   Social mobilization will engage the skills and resources of formal social and
                    professional groupings that can exercise effective influence for ending PBEF.

                    Social mobilization can both stimulate change and support and promote a
                    changed situation e.g. it was the mobilization of activists that resulted in the
                    passage of the PNDT Act; and it is through their efforts that the Act can be
                    given publicity and validity.

                    [Group Four stakeholders identified below, including NGOs, medical bodies,
                    woman’s groups and other civil society organizations will be mobilized.]

                   Behavior change/development communication will be aimed at changing
                    those behaviors that promote and lead to the continuance of PBEF.

                    The ideas and concepts contained in behavior change communication must be
                    matched by the ground reality e.g. it is meaningless to expect a family to
                    believe that PBEF is illegal, if sex determination services are freely available.

                    [Behavior change/development activities will be conducted with three groups
                    of stakeholders: Group Three (service providers) including doctors,
                    technicians, abortionists; and Groups One and Two (service recipients and
                    immediate motivators) including women, their families, their peers, local
                    health providers and so on.]
The advocacy strategy for ending the practice of PBEF is based on the belief
that intensive analysis and planning are essential for effective
interventions. Planning for each track (“tracks” are described in a later
section) will follow the “P Process”11. The components of the P Process are as

1. Analysis – listen to potential audiences; assess existing programs, policies,
resources, strengths and weaknesses; and analyze communication resources
(this will give us an idea of “where we are”)

2. Strategic design – decide on objectives, identify audience segments,
position the concept for the audience, select channels of communication,
design indicators, draw up evaluation plans, and design evaluation

                          Development           Management
                          Pretesting            Monitoring
                          Production            Implementation
                             3                                        4

          Strategic                                              5




                                                                     Planning for Continuity
               3.   Development, Pre-testing and revision and production – develop
               message concepts, pretest with audience and gatekeepers, revise and produce
               messages and materials, retest new and existing materials.

               4.    Management, implementation and monitoring – mobilize key
               organizations, implement the action plan, and monitor the process of
               dissemination, transmission and reception of program outputs, map outcomes

               5.    Impact evaluation – Process and impact evaluation: measure impact on
               audiences and determine how to improve future projects

               6.    Planning for continuity – adjust to changing condition: plan for

While it is tempting to work on many fronts, in the present situation we need to achieve
results. In order to achieve results we need to be able to define clearly what it is that we want
to achieve. Such a clear definition requires focus. And focus demands sacrifice i.e. the need to
prioritize action and identify foci for intensive inputs.

The first step is to make an accurate assessment of where we are and where we want to be.
Such an assessment will guide us as to the appropriate strategic framework – in other words
the most effective route to be pursued out of several alternative seemingly equally important
routes to achieve objectives.

                                     Where are we?

We are in a situation where the decline in sex ratios has reached grave and alarming
proportion. The rate of decline is accelerating – as indicated by falling sex ratios in the
youngest age groups. PBEF is contributing to this acceleration. If immediate action is not
taken to end PBEF, future social scenarios are likely to be very grim.

While sex determination technology and services are not openly available, most people agree
that such services continue to easily accessible. Their use, while more concentrated in some,
is not limited to any particular groups. It cuts across all social divisions and geographical
areas. Elaborate networks from the village level to the nearest urban ultrasound clinics for
referrals exist, where each link gets a commission from the clinics. Son preference is
intensifying with the growing adoption of the two-child norm wherein there is a desire for at
least one son. According to evidence from Punjab, the two-child norm, combined with the
easy availability of sex deselection services, has even begun to result in younger couples
opting for “designing” the sex composition of their families i.e. choosing to ensure that the
first born is a son. (This does not seem to be matched with the anxiety to ensure that the
second child is a girl.)

No systematic research has been conducted to identify and rank the reasons for PBEF, but it
is agreed that there are many obvious demand and supply side factors.
      Demand side factors

Underlying factors

Patriarchal attitudes and institutions, discrimination against girls and women and the
overwhelming desire for sons

Proximate factors

Decline in fertility, adoption of small family norm and the “intensification” of son
preference: Families are becoming smaller and son preference continues. In a bid to have at
least one son or to ensure that the first-born is a son, families are going in for sex selection.

Socio-economic imperatives: Sex selection is considered to be and inexpensive alternative to
raising girls. Since investments in girls (including educating them and giving them dowry at
marriage) accrue to the families into which they are married, families prefer to have boys. In
fact dowry, has been identified as a critical factor in decision to resort to PBEF.

Personal security concerns: The premium on “purity” at the time of marriage necessitates
that girls must be protected from men and boys (rather than controlling the behavior of the
latter). Most families consider having to provide this security as an extra burden.

Ignorance/inadequate understanding of the consequences of PBEF: In the anxiety to
conceive a son, women can sometimes be subjected to multiple abortions, which are
deleterious to their well being physical and psychological and contribute significantly to high
maternal mortality. In some cases they even undergo abortions based on inaccurate sex
detection. In the absence of counseling and support services it is unlikely that individuals or
families know the nature or extent of damage that can be done to the woman.

Ignorance/inadequate understanding of the law against it: It is likely that a majority of
people, especially those in rural areas, do not know of the existence of the law. If they know
of the existence of the law, they probably believe that it is not applicable to them and their
private, intra-familial decisions.

      Supply side factors

Underlying factors

The availability and use of the technology to determine sex before birth and the increasing
availability of pre-conception technologies.

Proximate factors

Simple means of earning money: Today ultra-sound machines cost as little as a few hundred
thousand rupees and its owners are likely to multiply their investment many times over in a
short period of time. Since it is illegal higher rates can be charged for fetal sex revelation.
Ultrasound scans do not involve any additional facilities (e.g. no hospitalization is required),
machines are portable and can be carried to a family‟s doorstep, and the client group is keen
to buy its service.

Widespread availability of services: This is likely to provide peer sanction to the use and
abuse of the machine.
      Active promotion of sex determination as a means to abort “unwanted” pregnancies (read
      “girls”): While they may not be doing it “openly” anymore, some health service providers
      are certainly “actively” promoting ultra-sound scans for sex determination.

      Ignorance/inadequate understanding of the consequences of sex detection services: It is likely
      that medical professionals too are unaware of the short and long term consequences of their
      services. Ultra-sonologists may not know the medical history of their services. Ultra-
      sonologists may not know the medical history of their client and they may not know that she
      is likely to have to undergo and abortion if the fetus is female (though this is unlikely). They
      may genuinely not know the effects that their actions have on the sex ratio or the long-term
      consequences of these effects.

      Ignorance/inadequate understanding of the law against it: It is possible that some doctors
      who provide sex determination services are unaware of the existence or content of the law
      and of their criminal liability if they reveal the sex of the fetus to the family. Even when
      doctors know the law, they are probably complacent and/or encouraged to continue providing
      services by the prevailing atmosphere of the lack of accountability. As mentioned earlier, few
      prosecutions have taken place to date relative to the extent of the availability of sex
      determination services. In such a situation, the law fails to play its deterrent role to the
      expected event. In the event of a prosecution, health service providers, like those in other in
      other fields of work, know that it is possible to “buy one‟s way out.”

                                                  Where do we want to be?

In the LONG term

      Our vision is that we want to be in a situation where society accords the same worth and
      status to women and men; where sons and daughters are equally valued.
      Impact of effective and continued interventions likely to be visible in 20+ years.

      What are the possible ways of realizing this vision? Intensive and multi-sectoral efforts, which are sustained, and
      comprehensive and effect fundamental transformations in gender relations and patriarchal institutional

In the MEDIUM term

      We want to be in a situation where there is widespread awareness of the macro-and micro-
      implications of PBEF among various stakeholders, including particularly service providers
      and service seekers, and a resultant decline in supply and demand side motivations. We want
      to be in a situation where there is widespread repugnance towards PBEF.

      Impact of effective interventions likely to be visible in 5 – 10 years.
      What are the possible ways of reaching these goals in the immediate term? Effective law enforcement, intensive
      and sustained efforts with law enforcers, civil society organizations and service providers in order to stop the
      supply of sex determination services.


      We want to be in a situation where sex determination services are not available.

      Impact of effective interventions likely to be visible in 2 – 5 years.
      What are the possible ways of reaching these goals in the immediate term? Effective law enforcement, intensive
      and sustained efforts with law enforces, civil society organizations and service providers in order to stop the
      supply of sex determination services.

11. What a National Advocacy Strategy Can Aim to Achieve
      Acknowledging i) that changes in attitudes and practice can only be sustained when root
      causes are effectively addressed, ii) that achieving these involves fundamental social
      transformations that are likely to taken several years to accomplish, and, iii) that the
      availability and utilization of sex determination services is contributing significantly to the
      accelerating decline in sex ratios, this Strategy, focuses on immediate and medium term
      outcomes. At the same time it is directly linked to, cognizant of and contributes to the
      achievement of the desired long-term outcomes.

      The National Strategy recommends the way/s to achieve changes in the behavior of the
      multiple stakeholders on account of whose acts of omission or commission the practice of
      the pre-birth elimination of females continues unabated and is on the rise; the Strategy
      links in with broader efforts to progress towards the vision of gender equality.

12.   Changing People’s Behavior
      Generally speaking, changing the behavior of individuals is a complex and challenging task.
      But ultimately all social change depends on the changed beliefs and behaviors of groups and
      individuals – be they policy and decision makers, civil society organizations. Service
      providers or service seekers. Before going further we need to appreciate some fundamentals
      of behavior change and how such change can be produced effectively, within a limited time
      frame and within an environment of restricted resources.

               a.      Too often it is believed that a
                       pamphlet here or a poster there or          Some principles for effective communication…
                       an expensively produced feature
                                                                      Identification of desired response before
                       film developed by subject experts               designing interventions
                       and creative persons will achieve              Behavior change based on improved
                       behavior change objectives and                  awareness levels, changed attitudes and an
                       consequently desired         social             enabling environment
                                                                      Basing the development of interventions
                       change. Nothing could be further
                       from the truth or more wasteful                  best practices
                       of limited resources. Another                    psychographic profiles of the target
                       common belief is that using                          group
                       multiple           communication                 unusual but appropriate and relevant
                                                                            creative treatment
                       channels is effective. This is true
                                                                        formative research
                       to a large extent but is potentially             participation of target groups in design
                       wasteful of resources if the                         of approaches and materials
                       selection of channels is not done              Messages are synergistic, coordinated and
                       strategically.                                  non-contradictory
                                                                      Strategically selected media channels
                                                                      Interventions are periodically examined
              b.       It is possible to accelerate                    for effectiveness
                       behavior change through several                Communication matched by concrete
                       means – improving awareness                     actions on the ground
                       levels, initiating and sustaining              Assessing impact and refining approaches
                       attitudinal changes, providing an enabling environment and so on.
c.   The most effective way to change behavior is to first identify the desired
     response and then to design appropriate “stimuli” (or interventions) that are
     most likely to achieve that response.

d.   To be effective, interventions need to be designed scientifically i.e. based on:

     i.     existing knowledge – past experiences, best practices, lessons learnt,
            views of experts and so on.
     ii.    specific knowledge of particular target groups; this knowledge is
            gathered through the research based development of psycho-graphic
            profiles; this information assists in the tailoring
     iii.   selecting the best of several alternative interventions; this is done
            through conducting “formative research” – where through pilot
            interventions with the active participation of target group/s the most
            appropriate interventions are selected and evolved
     iv.    Ensuring that the language and symbols used are culturally sensitive
            and comprehensible; that principles of human rights, including gender
            equality and gender sensitivity are an inherent part of all
            communication material.
     v.     ensuring that interventions stand out i.e. on a daily basis, especially in
            this age of information explosion, individuals are bombarded with
            thousands of messages; ensuring that our intervention can “cut through
            the clutter” requires effective creative treatment.
e.   Interventions within and among target groups should be synergistic,
     coordinated, appropriately sequenced and non-contradictory [this would
     require the development of a “common voice” and a “common platform”
     (through the development of coalitions and networks) on the part of those
     conducting the advocacy and communication activities].

f.   Interventions are periodically examined for effectiveness (evaluation research).

g.   Finally, the effectiveness of behavior change interventions are enhanced
     manifold if they are matched by actual actions on the ground e.g.
     communication promoting health seeking behavior is likely to be effective
     only if health facilities are available and accessible.

h.   It the interventions do not achieve the expected results, reexamining the entire
     cycle (schematically depicted below) is necessary and moves forward should
     be based on new levels of knowledge (knowledge gained in designing and
     executing the intervention/s.

          Current Response                             Desired Response

                                                      Behavior Change Intervention
          Degree of Success
13. Potential Target Audiences and Allies

     In order to define the route or strategy it is necessary to first answer the following question:

            Who are the different groups involved in the continuance/increase of PBEF?

     A number of individuals and groups are responsible for PBEF. If the female fetus, (indeed the
     very concept of the female fetus given pre-conception sex selection) is placed at the center,
     she is surrounded by a spiral, of those who influence the decision to eliminate her. These
     influencers are not compartmentalized but interact with one another; they may act in collusion
     and cooperation or they may be antagonistic.

     These individuals and influences, each of which has a role to play in either promoting or
     ending PBEF, can be categorized as follows:

             i.     Group One: The Service Recipient

     The primary service recipient is the woman who is pregnant or due to conceive. She may
     seek out the service out of her own “free will” (very rare) or because she is influenced (most
     frequent) by the next group of influencers or motivators. She may have to undergo several
     procedures (including multiple abortions) that may be detrimental to her physical and
     psychological well being.

            ii.     Group Two: Immediate Motivators

     The immediate motivators are those who motivate, inform, permit, encourage, pressurize,
     threaten or support the woman to seek out the service according to or against her will. This
     group consists of:

           husbands and other family members
           peers
           local health providers (e.g. TBAs and RMPs)
           religious figures and others

            iii. Group Three: Service Providers

     This group consists of those who promote, provide, conduct, aid and abet sex determination
     services and influence, advise, and enable woman to undergo PBEF.

     This group consist trained and untrained service providers under various systems of medicine

           allopathic doctors (including gynecologists, obstetricians)
           paramedics (including ultra-sonology technicians and operators)
           other health service providers
       iv.     Group Four: Social Catalysts

The silence or action of this of this group of civil society and other actors can very often bring
about social change. They can play an important role in creating public opinion, pressurizing
professionals and professional bodies, advocating with policy and decision makers, providing
support services (e.g. counseling), litigating, forming coalitions and alliances and so on.

              local leaders – social, religious and political leaders play an important role in
               influencing community opinions and attitudes
              medical bodies and fraternities – can provide guidelines for ethical practice,
               translate legislation into terms that are understood by medical practitioners, act
               as watch dog and disciplinary bodies recognize or derecognize (through
               incentives, licenses etc.) exemplary or condemnable behavior, address
               grievances of the medical community in situations of the misinterpretation of
               the law, assist in seeking and promoting out-of-court negotiation and
               settlement routes and so on.
              social activist, NGOs and woman’s groups – there are of course a variety of
               NGOs and woman‟s groups (including self-help groups); many roles can be
               played by them e.g. awareness raising, advocacy, acting as watch dog or
               pressure groups, providers of support services to women (e.g. counseling or
               shelter to women who are abused or fear abuse); they can form and stimulate
               the formation of powerful coalitions and networks.
              social development agencies – can mainstream specific issues of concern into
               their programs and support organizations, coalitions and networks
              professionals, researchers and academics – they play and can play an
               increasing important role in the search for and production of knowledge
               (especially in areas such as anthropological demographics) and in projecting
               future scenarios based on trend analyses
              journalists – can create or challenge public opinion through investigation and
              manufacturers, marketers and R&D personnel – of sex determination
               technological tools and methods can play and encourage others to exercise
               socially responsible behavior with respect to PBEF
              other civil society groups – can participate and enhance many of the above

               v.      Group Five: Policy/Law Makers and Implementers/Enforcers

              parliamentarians and legislators – the hands of all the actors involved in
               social change can be strengthened or weakened based on whether policy (and
               legislation) are progressive and grounded is social justice and principles of
               gender equality and whether the various arms of the state apparatus (legislative
               bodies, the judiciary, etc) promote an atmosphere of accountability or impunity
              social policy and decision makers – they represent the via media between the
               State and the citizens and play an important role in influencing both as well as
               specific groups such as health professionals, the media and multinational
              law enforcers – including specially appointed government agents (e.g.
               Appropriate Authorities, the police etc.) – the attitude and actions of these
               persons profoundly influence faith in or rejection of the State‟s position;
               committed, transparent and accountable activities on the behalf of law
       enforcers given appropriate training and codes of ethics can play an important
       part in controlling objectionable practices in society

       vi.    Social-environmental Influences

These influences may be specific or diffuse and range from:

      the mass media – the mass media, including the entertainment industry, play a
       critical role in shaping the way people think and behave; on the whole the mass
       media and popular culture are imbued with some of the most regressive
       stereotypes relating to the worth, position, role, and abilities of women;12 while
       these have proven difficult to change, the mass media can be encouraged to
       portray more progressive images of women and men and also to challenge
       stereotypes through both entertainment and critical analysis; the media,
       especially print and audio-visual (and increasingly the Internet), have a
       critical role to play in highlighting the issue of PBEF can its implications on a
       regular and sustained basis, this will help to keep the issue alive in the minds
       of all stakeholders and underline the social concern with which PBEF is
       regarded; it is critical that the media are sensitive to the fact that irresponsible
       actions on their behalf (e.g. advertising for sex selection) can have very
       profound negative implications.

      the larger social reality – this consists of the entire complex of cultural and
       religious values, beliefs, norms, mores and practices which may be directly or
       indirectly linked to social behavior in the entire spectrum of stakeholders,
       institutions and media; these are relatively resistant to change. Bringing about
       changes in its constituents can effect changes in the larger social reality.
                        WHO CAN MAKE A CHANGE AND HOW…
                                     Group Five Policy/Law Makers and Implementers/Enforcers
               Parliamentarians, legislators, the judiciary, ministries/departments, bureaucrats, special appointees
          They need to be made aware of what needs to be done and what they can do to end PBEF; they need to be alert
                 and responsive on an ongoing basis to expert advice and evidence provided by various sources

                                                    Group Five Social Catalysts
                                NGOs, women‟s groups, journalists, local leaders civil society groups
                                      can influence the other stakeholders directly or indirectly
They need to understand the enormity of the problem, the social injustice being perpetrated: they need to define and understand what
                  role/s they can play; and they need to be mobilized to influence all other groups of stakeholders

                                                         Group Three Service Providers
                                     Trained and untrained service providers under various systems of medicine
                                             Who disclose fetal sex and recommend and conduct PBEF

    They need to understand the implications of their actions and existing laws, possible penalties and how they can contribute to end the practice of PBEF.

                                                        Group Two Immediate Motivators
                         The husband, family members, peers, religious leaders who encourage, threaten, pressurize the recipient

                    They need to understand the implications of their actions and existing laws; they need to be persuaded to change their beliefs
                                                and attitudes regarding the position and worth of women and girls.

                                                               Group One Service Recipient
                                             The woman who may undergo procedures is the primary victim whose body
                                                                    and mind are abused

                                                            She needs information on risks and support;
                                                         She needs to be empowered and develop self-esteem
14.      Mapping Mindsets, Information Needs and Routes to Changing
         In order to understand what we must do to bring about eh necessary behavior change in our
         target audiences, we need to answer several specific questions.

                      a. What are their awareness levels, what are their attitudes and what are the actions
                         they do/do not execute?
                      b. What are their internal motivations and the external enabling factors that impel
                      c. Which of the identified groups (“audience segments”) should be addressed to
                         allow for the speedy and effective achievement of immediate, short and medium
                         term outcome?
                      d. What are their current responses to PBEF and what is the desired response we
                      e. How can their behavior/actions be changed and within what time frame (what
                         “messages” do they need to change their behavior)?
                      f. Who and what channels will need to be activated to bring about the desired

         In the following we examine one selected group of the service providers (Group Three) in
         detail. Of course detailed analyses of each group are essential for the development of specific
         advocacy and communication interventions. The analysis would be immensely enriched by
         research with the specific group. At the same time in view of the urgency of the situation, we
         may not have the luxury to wait for research results before starting on our advocacy and
         communication activities. Until such time as research results become available we can and
         must depend on accumulated wisdom. The following analysis has been made based on
         insights gained from reading documented material and interactions with subject experts and
         others working to end the practice of PBEF. Similar analyses would need to be done with
         each of the other groups (see Annexure 1).

With respect to              Awareness
PBEF, what are               - luck of appreciation of the full implications (macro-and micro-as well as short-and long-term) and role in skewing
their awareness              sex ratio
levels, what are             - lack of knowledge of the law
their attitudes and          - lack of knowledge of what to do
what are the                 doubts/confusion (“If abortion is legal and democratic citizens are free to choose, why should PBEF be
actions they do/do           objectionable?”)
not execute?
                             “My actions are unlikely to make any difference to the male to female ratio in society”
                             “The consequences of getting caught are not significant…I can buy my way out”
                             “Why should girls be brought into the would if they are going to suffer all their lives”
                             “These laws are in place only to victimize honest doctors and let the scoundrels go free.”

                             - enabling women to determine the sex of their babies
                             - conducting sex selective abortions
                             - promoting PBEF through inter-personal interactions and advertisements
                             - flouting the law
What are their         Internal factors
internal                          - desire to make money (from fees or kickbacks)
motivations and the               - social service – “I‟m averting the birth of an unwanted girl” or “I am helping a woman avoid an unwanted
external enabling                 pregnancy” (therefore protecting her from abuse within the family)
factors that impel                - conservative attitudes; belief that girls are “less worthwhile” and that the birth of sons is desirable
them?                             - clinical professional orientation – human body treated as “object” rather than subject with human rights and gender
                                  based needs
                       External factors
                       - demand for PBEF
                                  - lack of clear guidelines on what to/not to do
                                  - lack of law enforcement
                                  - environment of impunity: no fear of shame or penalty
                                  - falling ethical standards
                                  - easy availability of technology and machines
Which of the           This entails the identification of those groups whose changed behavior will have the greatest impact on the problem. This
identified groups      identification is done on the based on certain predefined criteria. Again as an example (see [*] above) the conformity of service
should be              providers (Group Three) to the selected criteria is analyzed below.
addressed to allow
for the speedy and               - size of target group (the smaller the better)
effective              SPs, as compared to many of the other groups (women, families etc.) are a finite group
achievement of
immediate, short                - possibility of addressing and monitoring all members (do they belong to larger formal groupings which are
and medium term                 reachable?
outcomes?              SPs usually belong to professional medical associations e.g. IMA, FOGSI and so on

                                 - nature of outcomes if interventions are successful (do the outcomes conform to the immediate/shot term
                                 objectives?. Will it affect both supply and demand side factors?)
                       If SPs stop providing PBEF related services this would spell the almost complete end of the current practice

                                - changed behavior of this group influences the behavior of others (potential for multiplicative effect)
                       Once supply closes down, it is likely it is likely that demand will die out: thus families will be forced to change their PBEF
                       seeking behavior

                                - fewer and direct channels of advocacy can be used (is the group literate? Can they respond to intellectual
                                persuasion? Can they respond to the written word?)
                       SPs are used to the written word and intellectual arguments

                                - simple methods to monitor changed behavior
                       SPs could be required to provide periodic information about their activities; peers could provide information on defaulters;
                       medical bodies could keep tabs on the activities of their members…

                                   - messages given to this group can be matched with concrete actions on the ground
                       Yes; law enforcement can be strengthened can be strengthened; defaulters can be booked; law abiding practitioners can be
How can their          It is likely that most medical practitioners will change their behavior if they understand the implications and consequences of
behavior/actions be    their actions. Therefore they need to understand the full impact of their actions (i.e. revealing the sex of the fetus). At the same
changed and within     time it is likely that there are doctors (“hard core”), who despite understanding the outcomes of their actions. Continue
what time frame        unconcerned. Both kinds of medical practitioners need to be fully aware of the law and the penalties that can be imposed under
(what “messages”       it, their obligations, the role and responsibilities of law enforcement bodies, the need to keep detailed records and reports and so
do they need to        on. They need to hear of medical practitioners who have lost their licenses under the law and the circumstances surrounding the
change their           seizure of their licenses. They, especially the hard cord, need to know that they can be subjected to raids or decoy operations
behavior)?             wherein they may be caught red-handed. Law abiding practitioners need to be commended as well as encouraged to report
                       (confidentially) on hard-core doctors. It is conceivable that with intensive efforts, it will be possible to address all doctors
                       within a period of 2-5 years.
                       It is very important to ally with doctors in the mission of ending PBEF. Alienating doctors, especially the bulk who are law
                       abiding, is likely to retard or subvert the mission altogether. There are accounts of machines and records being seized in clinics
                       in clinics that have already applied for registration but have not received appropriate documentation on account of delays
                       beyond their control. Doctors complain of the high-handed behavior of appointed authorities, of harassment and of having to
                       pay out large sums of money to avoid prosecution.

                       In the current anxiety to act. The ultra-sound machine. Rather than its misuse. Has come out to be the principal culprit. The
                       over-medicalization of pregnancy and unnecessary procedures being carried out on women are certainly matters of concern. But
                       doctors consider the ultra-sound machine to be an invaluable diagnostic tool for maternal and fetal conditions. It allows for the
                       detection of multiple fetuses, congenital deformities, malpositions, placenta previa, ectopic pregnancies and missed and
                       incomplete abortions. In many cases., ultra-sound scans prove life saving for the pregnant women. As things stand, several
                       doctors fearful of prosecution (and/or corruption), have stopped conducting scans altogether despite knowing that their women
                       patients are likely to suffer if detection of abnormalities does not take place or that may resort to unsafe abortions.

What are their         Current Response
current responses to   Revealing fetal sex has no consequences
PBEF and what is
the desired response   Desired Response
we seek?
                       I must not reveal the sex of the fetus because this has serious consequences: I must proactively discourage all processes
                       involved in PBEF.
Who and what         Several channels can used to address medical practitioners. Since doctors are literate persons and exposed to literature
channels will need   pertaining to their profession. It should be possible to get information across to them through creatively developed print
to be activated to   materials, which have been specially designed for them – pamphlets leaflets direct mailers handbooks and guidelines. Cogent
bring about the      arguments that dispel their doubts and explode myths would need to be provided. Print communication should be supported by
desired change/s?    other media materials that appeal to the medical community – audio-visual presentations, films, as well as conferences and
                     seminars. Medical fraternities should reiterate and support the government‟s position on PBEG with their members and
                     participate in changing the behavior and practice of doctors.

                     Doctors must be taken into confidence and their representative must necessarily be on forums where decisions are taken to
                     control their actions make amendments in the low or change their behaviors. Processes must control to be transparent. The
                     Government low makes and enforcers should employ a persuasive rather then disciplinary tone in their action. Only then will
                     medical practitioners ally with efforts to stop PBEF.

         15. The Advocacy and Communication Strategy
                Advocacy and communication interventions will take place simultaneously on three
                tracks corresponding to impacts desired (and possible) in the immediate medium and
                long-term. The impacts of various advocacy and communication activities are likely to be
                sequential i.e. stoppage of sex selected abortions (<5 years): widespread awareness of the
                micro- and macro- consequences of PBEF (5-10 tears): and gender equality (20+years or
                more – optimistically speaking.) Action on each track will contain a strategic mix of
                advocacy, social mobilization and behavior change communication activities.

                                                         Closure of sex
                                                         services/ 2-5 yrs
                                                                                            awareness of
           All activities                                                                   implications/
                                Track I                                                     5-10 yrs
           to start                                                                                                             Change in gender
           and /or              Track II                                                                                        perceptions/ 20+yrs?
           continue             Track III

         Track I

         Achieving immediate objectives

          In the case of PBEF, the availability of technology has interacted with a psychosocial need
          (the desire for sons) activating a vicious circle where supply creates demand and demand
          triggers supply. Our objective is to stop PBEF with immediate effect i.e. within the next 2-5
          years. This may sound like an ambitious objective, but given the urgency of the situation we
          have little choice other then to do everything we can to achieve it.

          One sure way to achieve this outcome is to isolate and block the supply of sex
          determination services. Once the supply of services close down it is unlikely that families
          will be able to take recourse to other means (except for the privileged few who may seek
          such services in other countries). Sex determination is highly dependent on modern
          technology. Which is in the hands of a few i.e. the Service Providers. This group needs to
          be persuaded to change its behavior through effective advocacy and matching actions on
          the ground i.e. low enforcement
While emphasizing the need to terminate the supply to achieve effective short-term
outcomes, it is acknowledged as completely necessary to work simultaneously with other
influences especially the social catalysts (Group Two in other to both speed up outcomes
and sustain effects.

Several supportive measures will need to be undertaken e.g. advocacy for amendments in the
PNDT Act and its promotion by legislators and state agencies. To add to the effectiveness
of efforts, widespread public awareness will need to be created with respect to the illegality
and consequences of PBEF and the nature and purpose of the PNDT Act.

Track II

Achieving medium-term objectives

Track II activities will support and strengthen those in track I. At the end of 10 years we
expect to achieve widespread awareness of the Amended PNDT Act as well as awareness
about the micro- and macro- consequences and implications of PBEF.

Activities will be this track will involve all the stakeholder groups, but the primary target
 group will be the Group Four Social Catalysts. The sub-groups within this grouping will be
 equipped with knowledge, skills and communication tools, to create awareness, and change
 attitudes and behavior. Their roles will be concretely identified. They will be encouraged to
 develop coalitions and networks, to act as watchdog and pressure groups, to strengthen the
 activities of low enforcement and other bodies, as well as to provide direct services (e.g.
 counseling) where possible. It is expected that the advocacy and communication activities of
 Group Four actors, will influence all the other levels of stakeholders.

Track III

Achiving the long term vision
Multifarious efforts need to be undertaken to create an environment where sons and daughters
are equally valued. Such efforts cannot take place in isolation or in relation to a single issue
(i.e. PBEF). They have necessarily to be linked to the larger complex of advocacy and
communication efforts that are already taking place.

In actual fact, Track III activities will not form a distinct set of activities.

          All Track I and Track II activities will be imbued with human rights principles,
           particularly non-discrimination, on the basis of gender. They will all promote the
           value and worth of female children and highlight the negative implications of son
    preference norms. Specific issues that lie at the root of son preference, such as the
    practice of dowry, will be addressed where appropriate and necessary.

   At the same time efforts will be made to incorporate and mainstream the need to
    end PBEF in all available advocacy and communication opportunities that deal
    with gender equality issues i.e. in the various sectors viz. health, women‟s
    development, education, and social justice to name a few. As mentioned earlier, all
    PBEF related communication and advocacy activities would be directly linked to,
    cognizant of and contribute to the achievement of gender equality goals.
 Where we are......
                                    Where we want to be......

            Sex Determination Before Birth
        Changing the Demand and Supply Situation

                                 Supportive Social and
                                 Cultural Environment

And where we
want to be                            No Demand
Track I: In the IMMEDIATE term

We want to in a situation where sex determination services become unavailable

Impact of effective interventions likely to be felt in 2-5 years.

     Target Groups       Resources   What needs to be               Means of A & C         Actions on the Ground
1.   Primary Target      Highest     Role of SPs w.r.t. declining   Mailers and print      Amended law passed
     Group                           sex ratio                      materials; hotlines;   Enforcement bodies in
     Service Providers               Responsibilities of SPs        websites;              place
                                     Requirements and penalties     guidelines;            Complaints bodies in place
                                     under law                      instruction            Raids/decoys
                                     Medical ethics                 manuals;
                                                                    discussion groups
                                                                    supported with a/v
                                                                    material; etc
2.   Secondary Target    High        Consequences of declining      Mailers and print      Amended bill put up in
     Group – I                       of declining sex ratio         materials; a/v         Parliament
     - Legislators                   Importance of amending law     materials; expert
     - Law Enforcers                 Understanding of effective     interactions; Q&A
                                     enforcement                    sessions
                                     Actions that need to be
3.   Secondary Target    High        Understanding of issue and     Mailers                Amended law passed
     Group – II                      implications                   A/v material           Enforcement bodies in
     - Medical bodies                Knowledge of the law and       Handbooks and          place
     - NGOs, activists               its application                manuals                Complaints bodies in place
     - Journalists                   Roles and responsibilities     Directories            Support and resources
     -Social                         Networking and alliance        Expert interactions    available from
     development                     building                       Published articles     government, development,
     agencies                        Supporting advocacy and                               and academic
     - Researchers,                  communication activities                              organizations
     academics                       Gathering and dissemination
                                     of knowledge and
4.   Tertiary Target     Moderate    Knowledge of the law and       Mass media             Amended law passed
     Groups Public at                penalties                      Folk media             Enforcement bodies in
     large (including                Consequences (and risks) to    All other              place
     women and men,                  individual woman and the       communication          Supportive health services
     immediate                       national of sex selective      “opportunities” e.g.   – e.g. counseling against
     motivators,                     abortions                      ranging from           PBEF
     women‟s groups)                 Girls‟ and women‟s rights      women‟s rallies to
                                                                    group discussions
                                                                    to encounters with
                                                                    health providers
Track II: In the MEDIUM term
We want to be in a situation where there is widespread awareness of the macro-and micro-implications of PBEF among
various stakeholders, including particularly service providers and service seekers, and a resultant decline in supply and
demand side motivations. We want to be in a situation where there is widespread repugnance towards PBEF and a
weakening of son preference norms. The group that can exercise the greatest amount of influence from grassroots to
policy level are the social catalysts.

Impact of effective interventions likely to be felt in 5-10 years.

     Target Groups           Resources     What needs to be                Means of A & C          Actions on the Ground
1.   Primary Target          Highest       Roles and responsibilities      Workshops/confere       Amended law passed
     Group                                 Nature of activities            nces with mother        Enforcement bodies in
     Social Catalysts                      can/should engage in            organizations           place
                                           How to develop coalitions       Expert interactions     Availability of
                                           and networks                    Guidelines/handbo       data/information Financial
                                           How to act as watchdog and      oks for                 assistance
                                           pressure groups                 training/orientation
                                           How to strengthen the           /discussions/Teachi
                                           activities of law               ng/learning
                                           enforcement and other           material (flipcharts,
                                           bodies                          flash cards etc.)
                                           How to provide direct           Effective a/v
                                           services (e.g. counseling)      material
                                           where possible                  Directories

Track III: In the LONG Term We want to be in a situation where society accords the same worth and position to women
and men; where daughters are as desired as sons.

Impact of effective and continued interventions likely to be felt in 20+ years.

     Target Groups           Resources     What needs to be                Means of A & C          Actions on the Ground
1.   Primary Target          Combined      The equal value of              Mass media              Equal rights and
     Group                   Ice           men/boys and girls/women        Opportunities to        opportunities supported
     Public at large         resources                                     interact                and promoted by multiple
                             of many                                       with/address large      sectors
                             sectors                                       numbers e.g. rallies    Framing and effective
                                                                           Piggy back gender       implementation of gender
                                                                           equality issues in      progressive legislation
                                                                           all other               Penalties and prosecution
                                                                           development             of those who violate the
                                                                           communication           rights of women
                                                                                                   Environment of freedom
                                                                                                   and security for women
                                                                                                   and girls
16. Development, pre-testing and production of materials
     The development, pre-testing and production of materials will take place at both the central
     and sub-national levels as appropriate. Advocacy materials will primarily be developed at the
     national level (these can be adapted for specific use at the sub-national level as necessary).
     Prototype communication materials and media plans will be developed at the national level;
     these will be disseminated to the states/regions and adapted/modified/added to within states as
     per the specific needs of the respective states and the guidance of the state/regional level task

     To give all the materials a common branding, identity and instant recognizability, a national
     logo and slogan will be developed and used in each instance. The logo and slogan will create
     a unity among all the various efforts taking place. These will also be developed through
     formative research, pre-testing and expert opinion.

     Communication materials / activities already underway. A number of advocacy and
     communication activities were initiated/commissioned before the development and
     dissemination of this Strategy. It should be ensured that efforts and investments that have
     been made while not being aborted are not at major variance with the Strategy. Existing and
     upcoming advocacy and communication materials/activities at the national and sub-national
     level that are in line with National Strategy should be strengthened and promoted. Where this
     is not eh case guidelines will be provided to relevant agencies on how to reorient
     materials/activities where necessary.

17. Research and Documentation Needs
     In addition to the opinions of experts and field based personnel, research, both official and
     independent, is essential to guide, validate and evaluate interventions, including advocacy and
     communication interventions, as well as to effect mid-course corrections. How detailed or
     how extensive a piece of research is well depend on many factors including the availability of
     resources – skills, funds and time. In the case of PBEF the most limited resource is time, as
     action needs to be taken immediately. However, this does not take away the need for research.
     It means that research needs will have o be prioritized and research will have to be designed
     in such a way that critical insights (for advocacy and communication) are made available at
     the earliest. In some cases we may be forced to proceed without adequate research; but
     research must go on and as and when results are available these should be incorporated into
     actions. With respect to PBEF communication and advocacy, there are many kinds of research
     with are required.

     Situational analyses: These need to be conducted at various levels – national and sub-
     national, in order to develop a systematic and an accurate understanding of the many
     quantitative and qualitative facets of the situation of PBEF. Situational analyses should be
     based on both secondary and primary data. Some of the questions such research could address
     with respect to PBEF are: How widespread is the practice in various groups? Where and how
     easily are services available? What is the effectiveness of law enforcement? What are the
    kinds and quality of reports and data available? What have been some of the lessons from
    advocacy and communication activities already conducted or in progress?

    Issue based: Issue based research adds to our understanding of particular aspects of a problem
    e.g. what is the incidence of abortion? How is PBEF related to birth order and birth interval?
    What is the socio-economic impact of sex selective abortions on the status of women? What is
    their demographic impact on the age structure of the population, population growth, total
    fertility rate, age at marriage, morbidity and mortality? What are some inter-community and
    inter-regional differences in the practice of sex selective abortions? Such research can further
    refine our ability to design and redesign effective communication.

    Formative: Such research needs to be conducted before the development of advocacy and
    communication material. This research provides an understanding of the mindset of specific
    target groups, their information needs, and their responsiveness to some rather than other
    channels of communication and creative treatment of material.

    Pre-test: After advocacy and communication material has been developed it needs to be pre-
    tested with a sample of the target group for whom it is intended. This helps to refine the
    material, gauge its acceptability and identify gross negatives.

    Evaluation: Evaluation research is essential to assess the effectiveness of advocacy and
    communication material. Mid-term evaluations allow for mid-course corrections and end of
    term evaluations helps identify lessons learnt. Such research provides guidance or the need
    and nature of further interventions.

    Who should conduct what research, and when, as well how research results and processes
    should be documented and disseminated should form an essential part of the
    advocacy/communication packages developed for PBEF.

18. Monitoring
    In order to track processes and their effectiveness it is essential to monitor them with the help
    of well-defined input (e.g. how may posters were printed?), output (e.g. how many people are
    likely to have seen the poster), and outcome (e.g. was there an increase in knowledge/change
    in behavior as a result of seeing the poster?) indicators. Impact indicators to measure reversal
    in declining sex ratio trends well also need to be designed. We need not wait for the next
    census to assess the impact of our efforts; sample surveys or analyses from existing records
    should yield adequate interim results.

    Not directly related to communication and advocacy interventions, are monitoring activities in
    reproductive health that would provide enriching insights to improve interventions. Databases
    need to be created where they do not exist and strengthened where they do, these need to be
    updated on a regular basis and information needs to be made widely available. Independent
    bodies and entities should have access to data to make and share analyses.
    The databases should have information that is deemed useful for the monitoring of activities
    related to PBEF and changes in sex ratios at birth. The registration of vital events needs to be
    made more thorough and precise. The kind of data and analyses required will of course have
    to be decided upon by subject specialists.

19. Operationalizing the Strategy
    Keeping in view the principles and strategy recommended in the national framework, detailed
    action plans for advocacy and communication will need to be developed at the national and
    sub-national level; this would require the translation of this national framework into Hindi and
    other local languages). The institutional mechanism to steer the implementation of the
    strategy needs to be defined at the earliest (see Annexure 2). It should necessarily incorporate
    expertise from the following fields

                  Gender
                  Medical
                  Legal
                  Communication (preferably planning and creative executives of a professional
                   development communication agency)
                  Media
                  Research
                  Government and non-government representation

    Among the specific tasks of this mechanism would be the following:

           a. Conducting an in-depth situational analysis – based on interactions with experts
              and research conducted with target groups, examining existing advocacy and
              communication material, and identifying gaps and needs.
           b. Prioritization of geographical regions.
           c. Identifying research and documentation needs
           d. Developing a detailed strategic design including – profiling target groups,
              identifying core messages, identifying appropriate media, defining reach of
              advocacy and communication efforts and expected results.
           e. Identifying commissioning and guiding appropriate agencies for the development
              of prototype advocacy and communication material; pre-testing and production.
           f. Developing a detailed management, implementation and monitoring plan
              (including the development of sensitive indicators).
           g. Developing a plan for impact evaluation for each of the three tracks recommended
              in the strategic framework.
20. Next Steps
    Recommended next steps are as follows:
                                                         It is likely that the advocacy strategy will
                                                         be successful if the following assumptions
          a. Constitute the implementation mechanism     on which it is based are correct:
             for the national advocacy strategy with          Genuine political will to address the
             immediate effect. Similar mechanisms              problem of PBEF
             should e developed at the state level.
                                                            Advocacy and communication
          b. The agenda, role and responsibilities of
                                                             interventions are matched by actions
             the mechanism and its constituents should       on the ground
             be developed.
          c. The framework of an action plan for            Law enforcement and supervisory
             advocacy, social mobilization and               bodies have received adequate and
                                                             appropriate training
             behavior change communication activities
             should be designed at the national/state       There are checks and balances
             level.                                          within the system to address
          d. The development, pre-testing and                dereliction of duty by law enforcers
             production of advocacy and
                                                            Advocacy and communication
             communication materials should be
                                                             decisions are appropriately
             coordinated at the central level.               decentralized, and
          e. Prototypes should be shared for
             adaptation/modification at the sub-            All materials incorporate the
             national level according toe local needs.       guidance and involvement of subject
                                                             experts, gender and communication
                                                                                                     Annexure 1
                                         Analysis of Stakeholder Groups

                                          Group One: Service Recipient
Role Definition:

Group          Awareness     Attitudes     Actions     Internal Motivation    External Enabling   Current and
                                                                              Factors             Desired
Women of
bearing age

Nature of Target Group                                                                            Remarks
Size                                                 Finite       Infinite
Possibility of addressing/monitoring all members     Possible     Somewhat      Impossible
Nature/number of communication channels required     Limited      Many          Extensive
Outcomes if interventions successful (changed        Yes          No
behavior = stoppage of practice?
Potential for multiplicative effect                  High         Medium        Low
Behavior change indicators                           Simple       Complex
Can messages to group be matched with on the         Frequently   Sometimes     Rarely
group actions?
Likelihood of changing behavior in the short term?   High         Medium        Low
                                                                                               Annexure 1   contd/-

                                      Group Two: Immediate Motivators

Role definition:

Group              Awareness     Attitudes   Actions     Internal Motivation    External Enabling   Current and
                                                                                Factors             Desired
Local Health
Other Local

(one table per sub-group)
Nature of Target Group                                                                              Remarks
Size                                                   Finite       Infinite
Possibility of addressing/monitoring all members       Possible     Somewhat      Impossible
Nature/number of communication channels required       Limited      Many          Extensive
Outcomes if interventions successful (changed          Yes          No
behavior = stoppage of practice?
Potential for multiplicative effect                    High         Medium        Low
Behavior change indicators                             Simple       Complex
Can messages to group be matched with on the           Frequently   Sometimes     Rarely
group actions?
Likelihood of changing behavior in the short term?     High         Medium        Low
                                                                                                                           Annexure 1 contd
                                             Sample Profile of Stakeholder Group

                                              Group Three: Service Providers
Role Definition: This group consists of those agents who determine the sex of the unborn life and advise, conduct or
enable women to undergo PBEF. If they stop and/or monitor the supply of sex determination services, PBEF could be

Group       Awareness         Attitudes       Actions        Internal                 External Enabling           Current           Desired
                                                             Motivation               Factors                     Key               Key
                                                                                                                  Enabling          Response
Group 3:    Lack of           “My work        Enabling       Desire to make           Lack of clear guidelines    Revealing fetal   I must not
            appreciation of   is unlikely     women to       money (from fees or      on what to/not to do        sex has no        reveal the sex
            the full          to make any     determine      kickbacks) social        loopholes in the law lack   consequences      of the fetus
Providers   implications      difference      the sex of     service – “I‟m           of law enforcement                            because this
            (macro-and        to the male:    their babies   averting the birth of    environment of                                has serious
            micro-as well     female ratio    conducting     an unwanted girl” or     impunity; no fear of                          consequences
            as short-and      in society”     sex            “I am helping a          shame or penalty
            long-term) and    “The            selective      women avoid an           widespread practice;
            role in           consequence     abortions      unwanted                 tacit sanction of peers;
            skewing sex       s of getting    promoting      pregnancy”               falling ethical standards
            ratio lack of     caught are      PBEF           conservative             easy availability of
            knowledge of      not             through        attitudes; belief that   technology and
            the law           significant…    inter-         girls are “less          machines
            lack of           I can buy my    personal       worthwhile” and
            knowledge of      way out”        interactions   that the birth of sons
            what to do        “Why            and            is desirable
            doubts/confusi    should girls    advertisem
            on (“If           be brought      ents
            abortion is       into the        flouting the
            legal and         would if        law
            democratic        they are
            citizens are      going to
            free to choose,   suffer all
            why should        their lives”
            PBEF be           “These laws
            objectionable?    are in place
            ”)                only to
                              doctors and
                              let the
                              go free.”

Nature of Target Group                                                                                                          Remarks
Size                                                            Finite                Infinite
Possibility of addressing/monitoring all members                Possible              Somewhat         Impossible
Nature/number of communication channels required                Limited               Many             Extensive
Outcomes if interventions successful (changed                   Yes                   No
behavior = stoppage of practice?
Potential for multiplicative effect                             High                  Medium           Low
Behavior change indicators                                      Simple                Complex
Can messages to group be matched with on the                    Frequently            Sometimes        Rarely
group actions?
Likelihood of changing behavior in the short term?              High                  Medium           Low
                                                                                                    Annexure 1 contd/-
                                            Group Four: Social Catalysts
Role Definition:
Group                 Awareness     Attitudes      Actions     Internal Motivation   External Enabling   Current and
                                                                                     Factors             Desired
Local Leaders
Medical Bodies
Social Activists,
NGOs, and
women’s groups
researchers, and
Other Civil Society

(one table per sub-group)
Nature of Target Group                                                                                   Remarks
Size                                                    Finite          Infinite
Possibility of addressing/monitoring all members        Possible        Somewhat      Impossible
Nature/number of communication channels required        Limited         Many          Extensive
Outcomes if interventions successful (changed           Yes             No
behavior = stoppage of practice?
Potential for multiplicative effect                     High            Medium        Low
Behavior change indicators                              Simple          Complex
Can messages to group be matched with on the            Frequently      Sometimes     Rarely
group actions?
Likelihood of changing behavior in the short term?      High            Medium        Low
                                                                                                    Annexure 1 contd/-

                                  Group Five: Policy and Law Makers & Enforcers

Role Definition:
Group                 Awareness     Attitudes      Actions     Internal Motivation   External Enabling   Current and
                                                                                     Factors             Desired
& Legislators
Policy and
Decision Makers
Law Enforcers
Advisory Groups

(one table per sub-group)
Nature of Target Group                                                                                   Remarks
Size                                                    Finite          Infinite
Possibility of addressing/monitoring all members        Possible        Somewhat      Impossible
Nature/number of communication channels required        Limited         Many          Extensive
Outcomes if interventions successful (changed           Yes             No
behavior = stoppage of practice?
Potential for multiplicative effect                     High            Medium        Low
Behavior change indicators                              Simple          Complex
Can messages to group be matched with on the            Frequently      Sometimes     Rarely
group actions?
Likelihood of changing behavior in the short term?      High            Medium        Low
                                                                                  Annexure 2
           Mechanism to Operationalize the National Advocacy Strategy

The Core Group for the National Advocacy strategy met for a daylong Retreat on June 7,
2002 to finalize the contents of the Strategy Document. Discussions were intensive and
business was carried over to June 11, 2002 to complete the review.

One of the most important issues that emerged on June 11 was the need for an institutional
mechanism to operationalize the National Advocacy Strategy.

The Government representative in the Core Group informed other members that there were
already a number of groups, committees and sub-committees in the Ministry of Health and
Family Welfare overseeing the implementation of the PNDT Act and related issues. Some of
these are:

             Technical Sub-committee for considering amendments to the PNDT Act
             Sub-committee on Implementation Strategy for implementing the Act
             Group for considering Research Studies
             Group for considering Video/Film Presentations

In view of the above the Government representative felt that yet another committee would not
be essential.

Other members of the Core Group (from PSS, WHO, UNFPA, NFI. PC, UNIFEM, CARE-
India and two independent consultants) however felt strongly that in the absence of a specific
institutional mechanism to operationalize the National Advocacy Strategy, the Strategy would
fall by the wayside and that advocacy and communication actions would not follow the
recommended strategic path. This would result in wastage of resources.

Given the urgency of the situation and the rapidly declining sex ratio, the group left that no
further time or resources should be lost. This would only be possible if a Strategic route to
advocacy and communication is followed and if all advocacy and communication efforts are
coordinated and impelled by a defined entity.

The Core Group recommended that it was not necessary to set up a brand new institutional
mechanism. It was conceivable to dismantle some of the existing groups and reconstitute
them for the purpose of operationalizing the Strategy. The mechanism they agreed should
incorporate expertise from the fields of gender, medicine, communication, media, and law as
well as have representation from the government and non-government sectors.

There was agreement that UNFPA had played a significant role in constituting the Core
Group and enabling the development of the Strategy. It was felt that the agency should
continue to cooperate with the Government to realize the Strategy and to set up the required
mechanism/s to do so.
   According to the provisional figures of the Census 2001, the sex ratio in the 0-6 age group, is under 800
females to 1000 males in 7 districts of Punjab and 3 districts of Haryana.
  The term “female feticide” has been used commonly to describe sex selective abortions contingent on pre-natal
sex determination through ultrasonography and amniocentesis. In this strategy, we use the more inclusive tem
“pre-birth deselection of females” (PEBF), because pre-conception sex selection technologies such as sperm
separation are also available and are likely to contribute to declining sex ratios.
  The two-child norm is being promoted through incentives or disincentives by state governments in Rajasthan.
Maharashtra. Madhya Pradesh, Andhra Pradesh, Uttar Pradesh and Haryana.
  UNFPA (2001)
          Sex Selective Abortions and Fertility Decline: the case of Haryana and Punjab. New Delhi: UNFPA
  Carvalho, C. (2001)
          Abortion used as contraceptive by teenagers: study, The Asian Age, May 19.
  Junhong, Chu (2001)
          Prenatal Sex Determination and Sex Selective Abortion in Rural Central China. Population and
Development Review, 27(2):259-281.
  Of course women‟s rights are likely to be infringed outside the context of the “marriage market” also, but eh
  Chu Junhong (2002) op.cit..
  Personal communication. NMC Reports are currently under preparation.
   Ravindra R.P. (1998)
          Female Feticide in Tamil Nadu: Report of the State Level Consultation, December 2-3, 1998, Chennai.
          Society for Integrated Rural Development (SIRD), Madurai.
   Piotrow, P.T. et al (1997)
          Health Communication: Lessons from Family Planning and Reproductive Health, Westport:Praeger,
          p,27 (adapted)
   One of the most popular soap operas on Indian television portrayed a pregnant daughter-in-law going in for an
ultra-sound scan to determine the sex of the fetus: the episode was watched by hundreds of thousands of families
all over the country (May, 2002)

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