Advancing Clinical Care and Medical Understanding in a Resource-Limited Setting: Lessons From the Aro Village Project in the Wake of the Affordable Care Act

The three largest facility providers of inpatient psychiatric services in the United States are not hospitals: they are general prisons (1). The prevalence of mental illness in the criminal systems arose following a failure to fund federally approved mental health care programs in the 1960s as a dearth of resources failed to match the ensuing care demand from public inpatient hospital closures (2). Indeed, the high prevalence of mental illness in prisons is a reflection of an under-resourced medical system (3).

Are there any alternatives to this medical onus given the pecuniary realities?

Although developed over 50 years ago in colonial Nigeria, Dr. Thomas Lambo’s Aro Village Project addressed head on health care dilemmas we face today to conciliate moralistic concerns about space, funding, and resources for mental health care with financial limitations. Colonial officials considered resources for psychiatric care too costly. However, Lambo, the first Nigerian psychiatrist, created a form of preferable mental health care by innovating, at the seams of politics, health care systems design and medical treatment. The Aro Village Project provides a historical example of how the enormous societal cost of psychiatric care can be mitigated by making intelligent and affordable investments in the way mental health care is delivered.

The Aro Village Project: Expanding Access to Psychiatric Care in a Resource-Limited Setting

With moralistic and pragmatic concerns about the asylum-based system that legally institutionalized the large and growing population of homeless mentally ill in the village of Abeokuta, Nigeria, the local colonial government decided in 1949 to invest in a new mental hospital that could treat, rather than contain, its occupants (4). Land was purchased, and the then resident Dr. Lambo was recruited to direct the anticipated care program. However, in following discussions, the new facility proved more costly than anticipated (5). Construction was delayed.

In 1954, 5 years after the initial planning meeting, Dr. Lambo, having graduated, arrived at Aro Mental Hospital and sought to create a care system despite the few pieces in place (6). He converted the completed employee housing quarters into a day hospital complex (see Figure 1) and addressed patient housing by turning to the abutting village space of Aro where he asked villagers to rent out rooms in their homes to patients.

The ensuing Aro Village Project enabled overnight care through a microeconomic project that deflected responsibility for patient care to the hospital, even though it was located in a physically separate place. As villagers feared the renowned violent behavior of the anticipated patients, Lambo installed a 24/7 village nursing station, placing health care workers within arm’s reach. Furthermore, he mandated a family member to live with and assist each patient as a prerequisite for patient intake, assuring villagers in opening their homes. Villagers often forwarded the rent received from the patients to the hospital to expand its electrical and plumbing system, providing Aro with unprecedented electrical lighting and running water.

The hospital also benefitted from this arrangement, as it improved the accessibility of clinical services at diminished costs. After providing electricity and water, the hospital recycled rent revenue by creating loans for families to renovate their homes, increasing the patient capacity of the village. Furthermore, villagers accepted labor as a form of payment and thus created a more flexible patient payment system. The Aro Village Project offered care to Nigerian psychiatric patients for the first time since being envisioned by colonial officers.

The Clinical Village: Enhancing Patient Care Through Synergy of Psychiatric Treatment and Delivery Structures

The Aro Village Project outgrew its immediate use as a temporary means for medical access and developed into a new standard of care that continues to be modeled (7). The improvements to patient care grew from Lambo’s deliberate efforts to respond to patient’s voiced preferences to avoid visits to the hospital (8). The joint efforts of family members, villagers, and nurses facilitated a clinical village environment that helped patients avoid the hospital. Family caretakers accompanied patients to and from appointments, maintained the patients’ living space, and engaged in family therapy sessions. Village elders coordinated patient care, which could include any combination of psychoanalysis, medications, and electroconvulsive shock therapy (9). Treatment providers also worked with traditional healers to guide group activities. Nurses were continually stationed to provide assistance in the villages (10). In 1956, roughly 300 patients sought vacancies in the village, while over 200 beds in the hospital remained empty. In response, a new day clinic was built directly into the village in 1957 (11).

This approach transformed societal preferences for treating mental illness and experiences of psychiatric care. In 1955, within the 60-mile radius surrounding Aro, for every patient admitted to Aro, 15 were cared for at home. By 1958, three times as many patients were brought to the Aro Village Project as the number of patients who were attended at home (12).

From Madness to Mental Illness: How the Aro Village Project Transformed Societal Experiences of “Wére”

The Aro Village Project garnered social support by reshaping Nigerian understandings about wére, the Yoruba term often translated as madness. Prior to the Aro Village Project, attempts to cure wére entailed beating patients with a “medical whip” (13). Employing medical interventions, particularly psychotropic drug therapy, Lambo gained local repute as “the man who carried a magic stick” (personal communication with Charles Femi Jegede, May 2011). Social integration of wére also played a crucial role in altering perceptions of madness (14). Lambo’s mentee who trained in the village noted rapid destigmatization, “because the news went around that patients who had been roaming the streets for years were now living with villagers with no problem” (personal communication with Micahel Olatawura, May 2011). The theory that wére was a curable mental affliction took root. Just as the introduction of psychotropics affected possibilities for care, they also enabled a reinterpretation of the nature of mental illnesses.

Principles Demonstrated: Access, Quality, and Social Responsiveness Despite Low Resources

The Aro Village Project demonstrates three main principles of efficacious mental health care despite resource restraints applicable to psychiatric health care reform in the United States today: access, quality, and social responsiveness (15, 16). That is, mental health care should be financially and geographically attainable and provided in a way that helps patients cope with their own mental health impairments. Furthermore, mental health care should be culturally appropriate and socially appealing. First, Aro improved access to mental health care through flexible payment systems and continual expansion depending on medical demand. Following the Affordable Care Act, fee-per-service models, even on a sliding care, continue to place a large financial burden on patients (17, 18). A patient-centered medical home model, already shown to reduce hospitalizations and costs in a primary health care setting, could also apply to mental health systems in severe cases (19). Additionally, access for lower acuity cases to medical homes could be extended by coupling this health care reform with methods of health care payment that take population health into consideration (20). Second, non-negotiable guidelines that were patient-centered and driven ensured that quality remained protected at Aro. Valuing services by patient outcomes can delineate minimum care standards; these can be feasibly enacted by incentivizing and financing bundle packages within our current health care system (21). Finally, the Aro Village care system was socially integrated in a financially stable manner, and thus it allowed both participants in the system and the general population to benefit from the arrangement in a way that was tangible. Programs that focus on socially integrating patients with mental illness can reduce the demand for care reliant on confinement. As the Aro Village Project demonstrates, creating synergy between patients’ social incentives, disease-related needs, and medical supply can be harnessed creatively to produce an affordable, sustainable, and effective psychiatric care system despite competing demands of a large illness burden and financial constraint.

Key Points/Clinical Pearls