It is widely acknowledged, that economic development cannot be sustained without positive population health indicators. Just as physical health outcomes, mental health outcomes can have an adverse impact on these indicators. The large burden of disease associated with mental, neurological and substance-use (MNS) disorders and the fact that these disorders are closely linked as precursor risks, comorbid conditions and outcomes of several other Non-Communicable Diseases (NCDs), poses a threat to the developmental trajectory of Bihar. This is especially because MNS disorders negatively affect all levels of society and carry substantial physical, social and economic consequences. Barriers such as stigma, discrimination, lack of mental health literacy and non-availability of mental healthcare at both public and private health institutions,is further worsened by easy availability of Alternate Practionersand high out of pocket expenditure on mental healthcare in Bihar. Theyrepresent formidable systemic barriers in accessing mental healthcare and social inclusion of affected individuals and their families.

The socio-economic impact of MNS disorders can be substantial in respect of both individuals diagnosed with MNS disorders and their care-givers. However, despite the disability impact and the economic burden associated with MNS disorders, affected individuals are not provided with any disability benefits under the current laws and schemes Bihar government. A wide range of cost-effective interventions for MNS disorders are available but are not generally implemented, especially among poor individuals, and those who are living in rural areas. The latest Mental Healthcare Act (2017) and the District Mental Health Programme (2000) has so far, not been completely implemented in Bihar. To address the current scenario of mental healthcare in Bihar, informed mental health policy making and implementation is required.For any such state action, the data available in respect of the mental health system in Bihar remains unsubstantial, at best.

In this context, this study aims to provide a situational analysis of the current Public Mental Health System (PMHS) of Bihar. It will assess the gaps and weaknesses in Bihar’s Public Health Institutions (PHIs) in terms of policy and legislative framework; mental health services; infrastructure; human resource; public education and links with other sectors, such as social welfare; integration of mental healthcare within Primary healthcare; and monitoring and research.[1]It seeks to expand the understanding on help seeking patterns of patients that are availing mental healthcare at PHIs and explore the systemic, structural and cultural barriers within the PMHS. It seeks to assess the socio-economic impact of MNS disorders on the patients and care-givers, to better understand the adverse impacts of illness from a socio-economic point of view, being conducted through administration of standardized tools.[2] The role of Alternate Practioners in providing mental healthcare in urban and rural areas of the state is unexplored but their role in providing general healthcare has been highlighted by many studies.[3] The high out of pocket expenditure on healthcare in Bihar, needs to be further explored specifically in the context of mental healthcare.[4]The integration of health and social welfare institutions run by the government is essential for delivery of mental healthcare services, rehabilitation and reintegration services. For this, it seeks to assess the general implementation of state government guidelines for social welfare institutions, and other applicable laws, such as theJuvenile Justice (Care and Protection of Children) Act(2015) and Protection of Women from Domestic violence Act (2005). Within the SWI component, the study specifically analyses the provisions of mental healthcare services and its implementation.

While, Quantitative methods has its place and usefulness, a numeric of 32.4% of years lived with disability (YLDs) due to MNS disorders, doesn’t tell you anything more. It doesn’t tell you what their mental health condition looks like, feels like, what the narrative is, what the meaning of MNS disorders is in their context, and so on. Qualitative data can be efficiently utilized for Policy making through various methods of Qualitative analysis in a sufficiently rigorous and respectable manner. With this approach, thestudy follows a mixed methods research design with an equal weighted interactive approachbetween Quantitative components and Qualitative components. For the Quantitative portion, Facility Survey based on the WHO-AIMS Tool will be conducted to assess the capacity of Public Health Institutions (PHIs) (n=22) in their ability to provide mental healthcare in Bihar. For Social Welfare Institutions (SWIs) (n=23) the facility survey would be constructed on the basis of a comprehensive list of Domains identified using the Delphi Method.

For the Qualitative portion, In-depth interviews with Mental Health Professionals (PHIs) (n = 22), Patients (PHIs) (n = 88), Caregivers (n = 88), Counsellors (SWIs) (n = 23),Alternate Practitioners (n = 10) will be conducted for a deeper understanding of issues of stigma and discrimination and other systemic, structural and cultural barriers faced by mentally ill patients in accessing mental healthcare and by mental healthcare professionals in providing/delivering mental healthcare; explore the help seeking patterns of the Patients; and assess the disability impact and the economic burden of MNS disorders on patients and care-givers. Post this Key Informant Interviews will also be conducted with key government officials (n = 6) of the state charged with responsibilities of Mental Health services establishment in Bihar and Superintendents of SWIs (n = 23)for a more holistic understanding of the issues and discrepancies within the public health institutions and the social welfare institutions, as comprising the PMHS in Bihar.