Introduction

With the Coronavirus Disease 2019 (COVID 19) spreading across 195 countries during 2020, it has exposed the actual state of public health all over the world. The same stands for India as well. Being already a developing nation the contagion has nothing but worsened the situation especially in the economic sector which was already in a precarious state.[1] The pandemic has taken a great toll on India’s weak public health system. During the time when the spread of the virus was at its peak in the months of June 2020 and July 2020, on one side there was huge surge in the number of COVID 19 cases which exceeded the number of existing hospital beds available for admission and on the other side with most of the public health care facilities getting converted to COVID designated hospitals, the worst hit were the non COVID patients. There was imposition of a series of nationwide lockdowns which further reduced the accessibility of the people. The falling national economy and nationwide lockdowns, had a great psychological impact on the people who were daily waged and dependent on day to day earning.[2] This was also accompanied with the rise in proportion of people who were unemployed. Above all this things, this pandemic could be seen as a great lesson and has shown us the importance of investing in the healthcare sector. In the post pandemic era with the vaccination campaigns already taking place among the healthcare professionals, the primary focus should be to strengthen the primary healthcare sector at the grass root level. This will not only reduce the burden of patients visiting the secondary tertiary care centres but also will increase the quality of health care. [3]

Weak primary health system has been a long standing problem for India to overcome which an approach of Comprehensive Primary Health Care (CPHC) through Health and Wellness Centres (HWCs) under the Ayushman Bharat Programme was launched in March 2018.  This initiative with two components is intended to provide a continuum of care services across the three levels of healthcare. The first component is the Pradhan Mantri Jan Arogya Yojana (PMJAY) according to which financial health protection of 5,00,00 Indian rupees per family per year to about 100 million families is provided and it covers around 500 million people based on Socio Economic and Caste Census (SECC) 2011 database.[4,5] Second component is upgrading the existing sub health centres (SHC) and primary health centres (PHC) into HWCs. It has been envisaged to set up 150,000 HWCs across India by 31^st December 2022. The HWCs include an expanded range of services and diagnostics. The services which  have been incorporated includes maternal and child health care, palliative, rehabilitative and elderly care, management of communicable and non-communicable diseases, eye and ear nose throat (ENT) care, oral health care, management of emergency cases and trauma. [6] In this focus has also been laid on the Mental Health which was not primarily focused at the primary healthcare level some years back. This proves that this initiative if implemented in a proper way can prove to be an important factor to resurrect the weak primary healthcare system of India.  It involves expansion of service delivery through population enumeration and empanelment of families at HWC, expanded palliative, curative, diagnostic, rehabilitative and palliative care services. The key component of upgrading the sub health centers (SHC) to HWC is the introduction of  Mid Level Health Provider (MLHP) who is known as the Community Health Officer (CHO).[7]

With the majority of the Indian population residing in rural areas, the setting up of HWCs has improved the accessibility of healthcare. This is certainly bound to have a psychological impact on the people residing in underserved areas. By the end of November 2020, 50,000 HWCs were operationalized which has led to improved access to affordable primary healthcare services for more than 250 million people.[8] This is set to decrease the patient load at the secondary and tertiary level health centers. This also indirectly takes the burden of the healthcare providers and improves their psychological well-being. With Mental health being now part of the CPHC, it has been thought that the people in the community would start availing the services at the SHC-HWCs as the first point of contact with the PHC-HWCs serving as the first referral point. In this regard, innovative use of technology like Tele-mental healthcare service, using mobile phones for risk identification, referral and follow-up as well as for data management at HWC can prove to be useful. Digital Nerve Centre (DiNC) Initiative which was launched at Kolar, Karnataka can be useful for rural and tribal population to access Mental health services at HWCs.[9] The HWCs are needed to be equipped with essential psychotropic drugs along with teleconferencing for specialist consultation by psychologists and psychiatrists on a regular basis from the District or the State level health facility. The various District Hospitals and Mental Health hospitals can be made stronger through collaborative care model which involves both community-based care as well as facility-based care services under District Mental Health Program (DMHP). Such hospitals could be linked with civil service organizations (CSO) offering mental health care service and HWCs. If this is accompanied by focused information, education, and communication (IEC) activities can eliminate mental health stigma/discrimination and might improve the access to mental health services which can aid in the effective implementation of the DMHP.^[10]

On the other hand it has also been found that it is highly feasible to start any mental health activities in a rural area, but these activities cannot be made successful unless the family as well as the community gets involved with the programme right from the beginning. In such initiatives, responsible persons from the local community has to be identified to act as nodal persons to conduct these activities.[11] The MLHP in the HWCs can play a role in the creation of patient support groups for psychiatric patients in the rural areas that can act as a mechanism to eliminate the stigma from the community and at the same time motivate them to avail the mental health services without any hesitation.[12]

Thus in short it can said that the ambitious initiative of Ayushman Bharat Program if implemented properly can play an important role in improving the primary health care system of India. This will

ultimately pave the way for an improved accessibility, affordability, acceptability, appropriateness and availability of quality mental health services as well which has been neglected till now at the primary level. With a focused and innovative approach as discussed earlier the societal barriers can be eliminated which would result in more people availing and accepting the services especially in the rural and tribal areas. Also the HWCs are envisaged to conduct wellness activities like yoga, games and competitions involving physical activities twice a week which can play an important role in decreasing the stigma among the people. Participating in such activities also contributes in the psychological wellbeing of the individuals.