Rural Health Systems: Laggards or Leaders

James E. Rohrer, Ph.D., Professor and Chair, Department of Health Services, Research and Management, Texas Tech University Health Sciences Center, Lubbock, Texas

The health of all populations is influenced by environmental hazards, individual lifestyles, biology, and access to good medical care. When it comes to particular rural populations, the mix of these risk factors may be unique; certainly, implementation of health programs is complicated by the twin problems of distance and small numbers of people served at a particular location.

These problems invalidate some of the organizational approaches developed for the delivery of health services in areas of high population density. For example, the notion that competition between local hospitals will enhance quality of care while forcing down costs simply does not apply in places where the population is too small to support several hospitals. The invisible hand of the market, which appears to be the preferred health policy tool of our generation, cannot be relied upon to assure quality access and efficiency of health services in rural areas. Similarly, prevention of environmental hazards, promotion of healthy lifestyles, and control of biological risks do not just happen by themselves.

On the other hand, rural people do not expect that either the state or the federal government will solve all of their problems for them. That cynical perspective brings with it a sigh of relief, since the notion of control by a government agency may not be very appealing to people who value self-reliance, independence, and privacy.

If neither the invisible hand of the market nor the heavy hand of government offers a solution, how then can rural health be improved? After all, a civilized society does not require that citizens residing in the smaller hamlets and farms be condemned to preventable disease and disability. Therefore, a middle way, or rather a constellation of "middle ways" will have to be implemented. Sometimes subsidies of rural programs will be necessary, though any subsidized program should be carefully monitored to assure that it is accomplishing its mission. Sometimes regulatory strategies will be appropriate; urban-based regional systems should be held accountable for serving all the people in their catchment areas, not just those who are easy to reach or highly profitable. Sometimes we may discover new ways to deliver services and protect health, ways that accomplish more with fewer resources. Ultimately, one of our goals should be to show the urban world that there are more efficient and effective ways to run health systems than are dreamt of in their philosophies.