Aro Village System of Community Psychiatry
in Perspective*
R. OLUKAYODE JEGEDE, M.D.I
The Aro Village system ofcommunity psychiatry was
started in Nigeria in 1954 by Dr. T.A. Lambo with the
aim ofmaking use o.ftraditional sociocultural resources
of the community in the treatment of mentally sick per-
sons. The history ofthe program ispresented, and advan-
tages and disadvantages are discussed. In addition, the
future role of the program in the health care delivery
system of Nigeria is discussed with emphasis on how to
guarantee the continuing relevance of the vii/age scheme
to the socioeconomic realities ofa changing society.
T he village system at Aro was established by Lambo in
1954 as part of an effort to study neuropsychiatric
conditions present in Nigeria and to find out the most
effective approach to treatment (I). One overriding con-
sideration in starting the experiment was Lambo's strong
conviction that community-based treatment of the men-
tally ill was particularly important in Africa owing to the
existence of a closely knit society in which a clearly
defined kinship system prescribed "definite roles and
mutual obligations."
Another consideration in the setting up of the village
system was the need to have the simplest treatment
method which takes local customs into consideration, an
outlook that in fact confirms Lambo's practical orienta-
tion. It was Lambo's belief that a psychiatrist in Africa
should be able to assume the role of a general practitioner
because the population from which his patients are
drawn expect a physician to be able to take care of all
sorts and conditions of illness. It is clear from the above
that Lambo's approach to treatment was deeply rooted in
the belief that effective treatment must be based on prac-
tical application of the knowledge of the society's cus-
toms and beliefs.
The History of the Aro Village System
The First Phase: The Day-Hospital Scheme
The day hospital project was started in October 1954as
part of the community psychiatry program of Aro Hospi-
*Manuscript received July 1980; revised October 1980.
'Senior Lecturer and Consultant Psychiatrist, Department of Psychia-
try. University of lbadan, lbadan, Nigeria.
Can. J. Psychiatry Vol. 26, April 1981
173
tal. The program was based in four villages which could
accommodate 200 to 300 patients. The villages were tra-
ditional villages in Aro on the outskirts of Abeokuta,
about 100 kilometres from the federal capital of Lagos.
Aro Hospital, a modern 200-bed psychiatric hospital,
was surrounded by the four villages. Each patient was
admitted to the villages on condition that a well relation
came to live with him there for the purpose of looking
after his basic needs (cooking, washing of clothes, and so
forth), taking him to the hospital for treatment in the
morning and bringing him back to the village in the
afternoon. Patients, their relatives and the ordinary vil-
lagers regularly attended social activities, such as films,
traditional plays and dances, in the hospital.
It was discovered that the experience of family
members staying with the patients in this way helped to
foster favourable attitudes in the family and the commun-
ity (of origin of patient and his relatives) toward the
patient, thereby facilitating his rehabilitation (2). The
first phase lasted two years.
The Second Phase:
Comprehensive Vii/age-Based Services
The first phase gradually merged into the second one.
The emphasis was on treating patients in the village
community without the patient going to the hospital at
all. In other words, the villages no longer served merely as
a dwelling place for the patient and his relative. All
treatment facilities were based in the villages, two of
which had clinics established in them while mobile clinics
visited the others. Dr. Lambo and his team, along with
village elders, formed a health council which became
responsible for planning, administration and execution
of health projects (including public health) for the vil-
lages. Regular meetings of the council occurred at least
once a month. When Dr. Lambo moved to the University
of Ibadan to take the Chair of Psychiatry, the staff of the
department of psychiatry replaced the Aro Hospital staff
in assisting him to run the treatment centres in the vil-
lages. As a result, there are currently no formal links
between Aro Village and Aro Hospital which is less than
one kilometre away. However, there is a rather close but
informal relationship between the personnel in the two
institutions. This facilitates referrals from one facility to
the other.
Treatment in the clinics in the villages covered a broad
174 CANADIAN JOURNAL OF PSYCHIATRY
range including electroconvulsive therapy, modified
insulin therapy, psychopharmacotherapy, group psycho-
therapy and abreactive techniques. The clinics had labor-
atories for routine investigations and also served as
administrative centres for the doctors and nurses.
Lambo (3) reports that he employed traditional healers
with wide experience in the management of psychiatric
patients. Under the supervision of Dr. Lambo and his
staff the traditional healers ran the social and group
activities of the village patients. Lambo found the tradi-
tional healers invaluable in furthering understanding of
the psychopathology and psychodynamics of psychiatric
conditions in the patients.
The villagers benefited in several ways from their
involvement in the community psychiatry program.
First,they received treatment in the villages when they
were physically sick so that only the more serious cases
were referred to the hospital. Second, the villagers were
encouraged to build additional houses, and their incomes
increased through renting rooms to patients and in other
ways. Third, the general living standards were improved
considerably owing to provision of pipe-borne water, a
better sewage disposal system and provision of jobs.
The Third Phase
It was planned that in the third phase in the develop-
ment of the Aro Village community psychiatry program
an expansion would be carried out to enable the facility
to treat up to 1,000 patients. Second, hostels were to be
built in and around the villages to facilitate increased
teaching and training of medical students and mental
health workers. It was also intended that a few beds
would be provided for treatment of patients with acute
physical illnesses (2). Unfortunately, these changes had
not occurred before Dr. Lambo moved from Ibadan to
Geneva.
The Functioning of the Village System Today
Organization of the Village System
Currently only one village, Aro Village itself, is func-
tional. The others have ceased functioning because of
shortage of staff and funds. The admission procedure
remains informal, and patients and their relatives con-
tinue to come from near and far to seek treatment. Most
patients are referred by relatives, friends or neighbours,
who have been treated in the village. At any given time
there are up to 40 patients (plus their relatives) living
there. There is a residential block with modern amenities
Table I
Psychiatric Admissions and Discharges at Aro
Villageand University College Hospital, Ibadan
1975
Male Female
Aro Village 57 52
University College
Hospital 5 88
Vol. 26, No.3
provided at cost to the more sophisticated patients who
may not be used to the less attractive conditions in the
typical village houses.
Patients with serious medical problems are not admit-
ted to the village but are referred to Aro Hospital or to the
University College Hospital, Ibadan, depending on the
nature of the physical illness.
There are four psychiatric nurses with many years'
experience who run a 24-hour service for admission and
treatment of patients in the village. The nurses live in or
near the village. They admit patients and start them on
treatment pending the arrival of consultant psychiatrists
from the Department of Psychiatry, University of Iba-
dan, who visit the village weekly. Treatment is essentially
as described above, although traditional healers are no
longer involved.
One important feature of treatment in the village is the
relaxed pace at which it occurs. There is no pressure for
beds, a perennial problem at the University College Hos-
pital, Ibadan. Consequently, patients are usually kept in
the village until both staff and relatives are satisfied that
the patients are well enough to go home. A few weeks'
notice are usually given before discharge, and this period
is often extended at the request of relatives. Many dis-
charged patients are seen for follow-up care in the psy-
chiatric clinics at the University College Hospital. Others
are referred to the nearest psychiatrists. Several patients
prefer outpatient treatment in the village even though it
involves considerable time and expense. Thus, some
patients prefer to travel from Lagos, where there are
psychiatrists, to be seen in the village by the visiting
psychiatrist.
The Department of Psychiatry, University of Ibadan,
located in University College Hospital, at Ibadan, a dis-
tance of90 kilometres from Aro Village, continues to run
the treatment facility located in the village. The nurses
and other staff(nurses' assistants, clerk, and so on) are all
employed by the university. One of the nurses is respon-
sible for the day-to-day administration but he is respon-
sible to the head of the Department of Psychiatry.
Table I shows admissions and discharges of psychiatric
patients at Aro Village and the University College Hospi-
tal, Ibadan in the years 1975 to 1977. It is clear from the
table that more patients are admitted to the village than
to the hospital, this being due to the previously menti-
oned fact that there are only nine psychiatric beds in the
hospital, while up to 40 patients can be admitted to the
village. The number of Aro Village patients is much
1976 1977
Male Female Male Female
84 73 80 64
17 66 13 73
April,1981 ARO VILLAGE SYSTEM OF COMMUNITY PSYCHIATRY
smaller than it would have been if duration of admission
in the village was as short as in the hospital. It will be
recalled that there is minimal pressure for early discharge
of patients from the village unlike the hospital where such
pressure is great indeed. This is reflected in the period of
time spent by patients in the two institutions, and this
ranges from several days to a few months for hospital
patients and a few weeks to one year for village patients.
Table I also shows a marked disproportion by sex in
the use of the two facilities: most patients admitted to
University College Hospital were female while, for Aro
Village patients, the females were relatively close in
number to males. The' main reason for this finding is that
there is a 6-bed female ward in the hospital whereas
males, for whom there are only 3 beds, are admitted to the
male medical ward. Two implications of this arrange-
ment are: (a) all things being equal, more females than
males will be admitted to the hospital; (b) while seriously
disturbed and disruptivefemale patients can be admitted
to the female psychiatric ward, which has a high staff-
patient .ratio, such patients, if they are male, are referred
to Aro Hospital because the male medical ward is under-
staffed and the available nursing staff usually have little
psychiatric training.
It may be concluded from the above that Aro Village
constitutes an important part of the treatment facility
offered by the Department of Psychiatry, University of
Ibadan.
The Role ofAro Village in Undergraduate Teaching and
Residency Training
Right from its inception Aro Village has been an inte-
gral part of the teaching program of the Department of
Psychiatry of the University of Ibadan. Medical students
regularly go to Aro Village and the adjacent Aro Neuro-
psychiatric Hospital for clinical clerkship. Currently, the
students spend two out of their six-week psychiatry post-
ing outside Ibadan. During this time they live in a hostel
in the hospital but not uncommonly some of them stay in
Aro Village if they are too many for the hostel. Psychia-
trists from the Department of Psychiatry supervise the
students' clerkship in Aro village while psychiatrists from
both Aro Hospital and the Department of Psychiatry,
Ibadan, supervise clerkship done at Aro Hospital. In the
village the students have an opportunity to see a wider
range of patients, especially actively psychotic patients,
than are available at the University College Hospital.
In regard to residency training the village plays an
equally important role. Residents have always provided
much of the service in the village under supervision of
consultant psychiatrists. Currently one or two residents
go to the village with a consultant psychiatrist every
Tuesday and Thursday. Both of them see patients and the
psychiatrist also use's the opportunity to teach the
resident.
Advantages and Disadvantages of Aro Village System
Advantages and. disadvantages of the village system as
operated by Lambo up to 1971 (when he left Nigeria) will
be considered first, then the current situation. As des-
175
cribed by Lambo (2) there were three sets of advantages
- social, medical and economic.
Social advantages included active involvement of the
community, with all its sociocultural peculiarities, in psy-
chiatric treatment; promotion of relaxation of negative
community attitudes; provision of a more natural envir-
onment for measuring the degree of social competence or
impairment, this being a striking contrast to the artifi-
cially structured environment of a psychiatric hospital;
and promotion of social adaptation and integration of
the patients as well as lessening of the social stigma
associated with mental illness.
The medical advantages, according to Lambo (2),
included relatively quick recovery, lessening of the risk of
social disability and reduction of problems associated
with after-care. The opportunity for interdisciplinary
cooperation and research and for teaching were among
the advantages of Aro Village system. It should be menti-
oned that no formal comparative study of the recovery
rate in the village has been done.
The economic advantages included relatively low cost
of running the program and effective utilization of mea-
gre human and material resources. Collomb (4) also
claims that his therapeutic villages in Senegal, based on
the Aro Village model, are also cheaper than hospitaliza-
tion by as much as 10-20 times.
The major disadvantage has been described by Lambo
(2); the program can only be carried out in agrarian
economies as found in developing countries. Difficulties
in the program might follow in the wake of social change.
Currently, the advantages and disadvantages of the
Aro Village system are essentially as described by
Lambo. The only additional comment is that difficulties
have indeed arisen in the operation of the system. Rapid
socioeconomic change is affecting treatment in the village
in important respects. For a few patients on treatment in
the village, it becomes necessary for the relatives to travel
to their homes for brief periods in order to take care of
one personal problem or another. Second, it is increas-
ingly difficult for patients, especially those from the
urban centres, to find relatives able and willing to stay
with them indefinitely. As a result, many times in the past
few years patients seen at the University College Hospital
who were asked to go to Aro Village for admission
because of bed shortage at the hospital have had to be
treated as outpatients because none of their relatives
could go to the village with them.
In the village itself, it is not uncommon for several
relatives to take turns staying with a patient or for a
patient's relative, who has to go away for one ortwo days,
to ask another person in the village to take care of his
patient while he is away. In spite of this most patients at
Aro Village have very dedicated and concerned relatives
who enthusiastically stay with them throughout their
treatment.
The Future of Aro Village System of Treatment
Although its mode of functioning has changed to some
extent, the Aro Village system of community psychiatry
176 CANADIAN JOURNAL OF PSYCHIATRY
continues to play an important role in the treatment of
psychiatric patients in Nigeria. Eloquent testimony to
this is provided by the fact that most patients are referred
by those who have benefited from treatment in the village
in the past and by patients' willingness to travel several
hundred kilometres to come to the village, often passing
by other psychiatric institutions in the process. The fact
that the village system has been replicated in other parts
of Nigeria and in other African countries is further
testimony to the significant role of the system (2,4).
What will become of the Aro Village system as Nigeria
changes from its present agrarian orientation and
becomes an industrialized country? Will the village sys-
tem die slowly because oflack of relatives to stay with the
patients? In answering these questions we will pay atten-
tion to certain issues. First, in spite ofthe general belief-
and there is some evidence for it - that family ties are
weakening, many persons still have the traditionally
strong sense ofloyalty and obligation to their relatives, as
a result of which they will not hesitate to sacrifice time
and money for taking care of sick relatives. As long as this
sense of duty exists, there will be a reservoir of relatives
willing to accompany patients to Aro Village and similar
facilities.
However, current experience shows that given willing
relations, there may still be other difficulties militating
against their going to the village. The increasing complex-
ity of urban life, especially the trend towards a wage
economy, limits the number of people who can afford the
time to stay indefinitely with a sick relation. Thus, while
the woman who is a housewife or a petty trader may be
able to leave home or business without serious economic
repercussions, a person who works in an office or a
factory will lose his job if he stays away without authori-
zation, or if he is absent for too long even if due permis-
sion has been given. It is clear then that as more people
participate in the wage economy, the number of those
available to engage in such activities as accompanying a
relation to Aro Village will dwindle. This development
will also affect the practice of traditional healers as they
usually have psychotic patients along with the well rela-
tives of the latter living with them during treatment.
The Aro Village system will remain relevant to the
needs of the Nigerian society for a long time, given the
social and economic advantages mentioned previously.
What is needed then is to make it easier for interested
persons to accompany their sick relatives to Aro Village
in spite of the changing nature of the economy. One
possibility, which has already being tried, is for a few
relatives to stay with the patient in rotation, one at a time.
This arrangement ensures that no single person stays with
the patient for months on end.
Another possibility - and it is not unrelated to the last
one - is to guarantee relatives' wages while they stay
with patients in the village. This could be part of a nation-
wide health insurance program. It will be more economi-
cal for a person with a relatively low income to take a few
months'leave with pay than for the patient to stay in the
hospital (with its high maintenance cost) for the same
Vol. 26, No.3
period of time. If this suggestion is adopted, it becomes
easier for several employed relatives to share staying with
a patient, each person staying for a month or so. It should
be obvious that it will not be economical for highly paid
workers, unless they are on annual leave, to participate in
the village treatment under the suggested scheme. Never-
theless, most people earn relatively low incomes, which
from the economic point of view, makes the guaranteed
wage scheme workable.
In spite of incentives to relatives to stay with patients in
the village, there will be some persons who have no
available relatives to accompany them to the village.
Such a situation is bound to occur with increasing fre-
quency partly because of the geographical mobility and
other recent developments, such as industrialization,
which result in people living and working far away from
their relations. The possibility of employing special
assistants to stay with such patients in the village should
be explored. Again, this approach, which should be part
of a comprehensive national health program, has the
advantage of lower costs in that village-based treatment
is facilitated, thereby minimizing the need for expensive
hospital treatment. For emphasis it should be mentioned
that the three approaches suggested for ensuring con-
tinued use of the village system - namely, rotation of
two or more relatives instead of one relative staying with
a patient throughout his treatment, guaranteed wages for
employed relatives who stay with patients in the village,
and employment of assistants to stay with patients with-
out available relatives - are not mutually exclusive.
Indeed they complement each other, and the first two are
interrelated as has been pointed out earlier.
Conclusion
The Aro Village system of community-based psychiat-
ric treatment, while not an entirely new idea in that it was
based on the practice at Gheel (5), has been a major
contribution to psychiatric treatment in Nigeria and
other agrarian economies of developing countries, espe-
cially those of Africa in general, hence its replication in
Senegal by Collomb (4,6). The resounding success of the
scheme derives from the practical application of the tra-
ditional sense of obligation of the African to his kinfolk
in time of need.
The preference of Nigerians, especially those in the
rural areas for traditional healers when seeking treatment
for mental illness, which has been shown in Harding's
study in Nigeria (7), along with the widespread use of
traditional healers in primary health care facilities (8),
suggests a large-scale replication of a modified form of
the Aro Village system in other parts of Nigeria. What is
being recommended here is the use ofa traditional healer
as an assistant to the nurse in charge of each village, as is
done in the villages started by Collomb in Senegal (4).
As has been discussed in greater detail elsewhere (9), I
support incorporation of traditional healers into the
health care delivery system so as to facilitate total popula-
tion coverage for treatment of physical and mental
illness. However, such integration will among other
April, 1981 ARO VILLAGE SYSTEM OF COMMUNITY PSYCHIATRY
things necessitate trying to change definitely harmful
treatment practices (such as flogging and chaining of
patients) of traditional healers through appropriate re-
orientation educational measures. Traditional healers
can and should play an important role in treatment of
mental illness not only in Aro Village-type treatment
centres, but also in general hospitals and elsewhere.
In regard to Lambo's intention to extend treatment
coverage at Aro Village to a thousand patients, it appears
that this proposal may not yield desired benefits as prob-
lems due to overcrowding and personnel shortage may
then arise. Location of similar villages, which can cater
for up to a few hundred patients, in everyone of the 19
states of the country would appear to be more desirable.
Several states at present have no psychiatric facilities
except those provided by traditional and/ or religious
healers: Initially some of the proposed villages may have
no access at all to psychiatrists because they are in short
supply (10), in which case they will depend on nurses as
the sole treatment personnel.
The relatively meagre financial and human resources
of Nigeria and other developing countries demand the
use of cheap and effective methods of treatment. The Aro
Village experiment is thus a bold and imaginative
attempt at achieving this goal. Because it is based on, and
derives its success from, the sociocultural peculiarities of
the society, it must, if it is to maintain its relevance, be
evaluated constantly in view of the rapidly changing
nature of the society, hence the importance of the three
suggestions aimed at adapting the present organization
of the village to meet the needs of a society in transition.
References
I. Lambo T A. A plan for the treatment of mentally ill in
Nigeria. In: Linn L. ed. Frontiers in general hospital psy-
177
chiatry. New York: International Universities Press
1961 :215-231.
2. Lambo T A. Patterns of psychiatric care in developing Afri-
can countries. In: Kiev A, ed. Magic, faith and healing.
London: MacMillan, 1964:443-453.
3. Lambo TA. The village of Aro. In: King M, ed. Medical
care in developing countries. Chapter 20, London: Oxford
University Press, 1966.
4. Collomb H. L'economie des villages psychiatriques. Soc
Sci Med 1978; 120:113-115.
5. Lambo TA. The village of Aro. 1964; Lancet ii: 513-514.
6. Collomb H. Recontre de deux systemes de soins. A propos
de therapeutiques des maladies mentales en Afrique. Soc
Sci Med 1973; 7:623-633.
7. Harding T. Psychosis in a rural West African community.
Soc Psychiatry 1973; 8:198-203.
8. Maclean U. Magical medicine. London: Penguin Press,
1971.
9. Jegede RO. A study of the role of socio-cultural factors in
the treatment of mental illness in Nigeria. Soc Sci Med (In
press).
10. Jegede RO. Nigerian psychiatry in perspective. Acta Psy-
chiatr Scand (In Press).
Resume
Le Dr. T.A. Lambo a instaure en 1954 un systeme de
psychiatrie communautaire de villages Aro dans Iebut de
tirer avantage des ressources socio-culturelles tradition-
nelles de la communaute dans Ie traitement d'individus
souffrant de maladie mentale. On retrace I'histoire de ce
programme, tout en discutant de ses avantages et de ses
inconvenients. De plus, on examine Ie role quejouera ce
programme dans Ie systeme nigerien de sante mentale et
surtout lafacon de garantir lapertinence de la continuite
de cette structure de villages en regard des realites socio-
economiques d'une societe en evolution.