Why Rural Health Stays Broken (And Why That's Deliberate)
Rural health isn't the problem - it's the solution that threatens the status quo
For years, I fought to prove rural health was good enough. I spent countless hours crafting business cases that demonstrated rural allied health professionals could deliver quality care. I gathered evidence showing rural communities weren't asking for gold-plated services; just equitable access to what urban areas took for granted.
I was asking the wrong question entirely.
The question isn't whether rural health can be fixed. It's why those with the power to fix it choose not to.
The Revelation That Changed Everything
The breakthrough came when I stepped back from the frontline advocacy that had consumed years of my mahi. Away from the relentless cycle of proving rural was "good enough," I could finally see what was actually happening.
Rural health isn't broken because it's too hard to solve. Rural health stays broken because fixing it would expose the artificial scarcity and professional gatekeeping that keeps our entire health system inefficient.
(Photo supplied by Dr Sarah Walker)
When you're fighting for scraps, you don't question why there are so few to go around. You just fight harder. But once I stopped trying to prove we deserved more crumbs from the table, I started asking who set the table in the first place, and why they needed us to stay hungry.
The Professional Gatekeeping Game
Here's what becomes visible once you stop accepting the premise that rural health is naturally disadvantaged: the systematic professional gatekeeping that maintains artificial scarcity everywhere.
In rural Aotearoa, when Martha the physiotherapist covers three towns because there's no one else available, she develops diagnostic reasoning across multiple specialties, manages complex cases without backup, and coordinates care across agencies and communities. She becomes exactly what health systems claim they need: an integrated, adaptive, systems-thinking practitioner.
But here's the uncomfortable truth: if we acknowledged Martha’s capabilities and removed the artificial barriers that restrict her scope, rural health outcomes would improve. And then urban areas would have to explain why they maintain professional boundaries that limit patient access and system efficiency when there's clear evidence those boundaries aren't necessary for quality care.
Rural health professionals develop the integration and adaptation capabilities that urban health systems spend millions hiring consultants to teach. They solve resource constraint challenges that urban managers attend expensive courses to understand. They demonstrate what's possible when professional tribalism takes a back seat to patient outcomes.
This terrifies the gatekeepers.
The Economic Inversion Nobody Talks About
There's another layer to this deliberate maintenance of rural health disadvantage that we rarely name directly. Rural communities produce what sustains urban areas; feeding, sheltering and clothing us all, making them indispensable to the entire country. Yet they're constantly measured by urban convenience standards and found wanting.
Rural communities don't just grow your vegetables and generate your electricity. Rural health services develop the innovation, integration, and adaptive expertise that your urban health system desperately needs but doesn't know how to access.
When rural practitioners work across traditional professional boundaries because they have to, they're not "making do." They're pioneering what modern healthcare actually requires: professionals who can think systemically, adapt rapidly, and integrate seamlessly across disciplines and communities.
But acknowledging this would mean recognising that rural communities aren't charity cases requiring urban assistance. They're innovation labs producing solutions that urban areas need to learn from.
That recognition would fundamentally shift power relationships. And power, once threatened, defends itself.
What Happens When We Stop Asking Permission
I've watched rural allied health professionals demonstrate capabilities that officially "can't" be done. Speech language therapists providing high-quality intervention for children in areas where urban colleagues claimed it was impossible. Physiotherapists working alongside GPs in primary care roles that urban health services pay expensive locum GPs to fill. Occupational therapists managing complex community integration that urban specialists handle through expensive multidisciplinary teams.
But instead of celebrating these innovations and scaling them system-wide, the response is typically to remind everyone of the "proper" professional boundaries and warn against "scope creep."
Because if rural areas prove that artificial professional barriers can be safely removed while improving patient outcomes, then urban areas have to explain why they maintain those barriers when they clearly limit system efficiency and patient access.
The Strategic Opportunity Hidden in Plain Sight
Here's what becomes possible when we stop treating rural health as a charity case and start recognising it as the R&D department for health system innovation:
Rural communities become proof-of-concept sites for what happens when we prioritise patient outcomes over professional territoriality. They demonstrate how health systems work when artificial scarcity is removed and integration is prioritised.
Instead of trying to make rural health look more like urban health, we start asking what urban health could learn from rural innovation.
Instead of gatekeeping professional roles to protect urban hierarchies, we start scaling rural-proven integration models that improve access and outcomes.
Instead of maintaining artificial barriers that create inefficiency, we start removing the obstacles that rural practitioners have already proven unnecessary.
Why This Requires Systematic Thinking
This isn't about individual rural services proving their worth or isolated allied health professionals pushing scope boundaries. This is about systematic recognition that rural health challenges reveal solutions applicable across the entire health system.
But scaling these insights requires more than good intentions or pilot projects. It requires systematic frameworks that help decision-makers see rural health innovations as scalable solutions rather than special exceptions.
It requires tools that help rural communities recognise their strategic advantage rather than accepting systematic disadvantage.
It requires approaches that make visible the artificial barriers maintaining inefficiency across our health system, and provide practical pathways for removing them.
This is why we need systematic frameworks for rural health equity. Not because rural communities need special help, but because rural communities have already developed solutions that the entire health system needs.
The Framework We're Building
The Rural Health Equity Framework™ isn't another policy document asking for rural health to be treated fairly. It's a strategic tool for recognising and scaling the innovations that rural health has already developed.
It's designed to help decision-makers see rural health as essential infrastructure rather than expensive charity. To help rural communities claim their strategic advantage rather than accept systematic disadvantage. To help health professionals work to their full scope rather than within artificial boundaries.
Because once we become power literate about rural health equity, we stop accepting that some communities should be grateful for healthcare crumbs. We stop believing that professional gatekeeping serves patient interests. We stop treating geographic and professional discrimination as inevitable features of our health system.
Instead, we start building health systems that work for everyone. We start recognising capability wherever it exists. We start removing the artificial barriers that keep our health system inefficient and inequitable.
The framework launches soon. But first, we needed to see clearly what's been hidden in plain sight.
The question isn't whether we can afford to fix rural health. The question is whether we can afford to keep ignoring the solutions rural health has already developed.
What artificial barriers has your rural community already proven unnecessary? Share your innovations in the comments, because the rest of the health system needs to learn what you've discovered.
#RuralHealth #HealthWorkforce #AlliedHealth #SystemicChange #HealthEquity #PowerLiteracy
Dr Jane George is developing the Rural Health Equity Framework™ based on her doctoral research and strategic health leadership experience. Her mahi focuses on removing artificial barriers that maintain health system inefficiency and inequity.