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This is the first in the Thrive Rural Field Perspective Series, describing the main trends and catalysts for change that emerged from scans of the primary approaches and practices currently being used in rural economic and community development and in rural public health and health care. This brief also highlights how accelerating connections between health and development can propel rural prosperity. Access a version formatted for printing here.

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Context

Rural regions, economies and communities are complex and dynamic systems. Whether they prosper or struggle is often a matter of how well local people, organizations and institutions can adapt, work together, leverage resources, and see a future for themselves. Rural areas, like all places and economies, are vulnerable to global economic trends and shifts, natural and unnatural disasters, and the effects of long-term exclusionary policies that have segregated too many from opportunity. Rural places share a challenge faced by other communities experiencing inequities: for decades, many public and private policies and practices, whether intentionally or not, have created barriers to building healthy rural communities and economies. When specific attention is not paid to eliminating these barriers, policies and practices at times exploit rather than enhance rural-based resources, making it harder for rural places to access investment because of criteria that, wittingly or unwittingly, preference urban applicants and exclude rural communities from decision-making processes.

The COVID-19 pandemic has laid bare the results of these decades of disinvestment in and neglect of rural. Dealing with the coronavirus has overwhelmed rural systems that support healthy communities and undergird local economies; it has also highlighted the limits of local action despite extraordinary local volunteer and collaborative efforts to counter the rural fallout.

The pandemic also showed in stark relief how different components of rural regions, economies and communities are interrelated and interdependent. Local businesses closed, many schools went virtual, people lost their jobs, and many lacked adequate health insurance. Families were trapped in their homes, often without internet access needed to enable remote working and learning. Resistance to public health directives led to the spread of the virus and strained rural health systems, already seriously depleted and in financial jeopardy, to the breaking point. Early federal government efforts during the pandemic to keep businesses afloat unintentionally bypassed those in rural areas because of a lack of attention to access barriers faced by firms in rural communities. For example, the mainstream banks that were utilized to operate Paycheck Protection Program lending had largely been dismantled in much of rural America due to consolidations with urban-based banks or closures over the past decades.

Yet, despite these barriers, some resilient rural communities found ways to support their businesses, provide local services and supports for families, and generally keep their systems going. Some of these efforts were innovative responses in the moment. Others were the results of systemic changes already underway in rural regions, economies and communities that have been imagining different futures for themselves – reducing their vulnerabilities; seeing the links between economic development, health, prosperity and well-being; and doing their best to act in ways that connect and blend their development and health objectives and actions to produce better results.

In this issue brief, we look at two fields where modest but important systemic changes have been evident for several years: economic development and health. We do so by describing the main trends and catalysts for change that emerged from our scans of the primary approaches and practices currently being used in rural economic and community development and in rural public health and health care. We also explore the intersections and connections between these areas to show how positive changes might be accelerated.

Trends in Rural Economic Development

We recently conducted a scan of rural economic development approaches and practices based on interviews with over 40 experts who represent a range of perspectives and geographies, and reinforced by a review of available literature on established economic development theories along with newer, emerging frameworks. We found a field that is adapting and evolving to reflect the changing realities facing local and regional economies, a growing interest in innovation and experimentation across the country, and an influx of new, younger and more diverse practitioners. Our work identified six important trends gaining momentum in rural development.

• Shifting from Recruitment. There is a growing understanding that the long-lived core strategy of building local economies by recruiting businesses from elsewhere in the United States and other nations should no longer be the primary thrust of economic development, especially in rural regions. Instead, economic development strategies must focus on creating the conditions that retain and support existing businesses and other economic generators (such as hospitals or community colleges) and that help entrepreneurship grow and succeed. Even in rural places in which attracting outside businesses remains a viable economic development strategy, there are moves to make such efforts more targeted, strategic and accountable.
• Building on Assets. Building on community and regional assets is an increasingly adopted principle in rural development: that is, using local strengths as the basis for product and service innovation, small business development, marketing and investment. These assets go well beyond financial, as important as they are, to include intellectual, individual, social and political capital – that is, the ideas, skills, relationships and connections that are at the heart of community vitality – and a rural region’s unique assets of “place” found in its natural, built and cultural assets. The WealthWorks development approach, for example, encourages communities to address and connect all eight of those asset or capital types in the process of constructing a value chain of development effort that builds local wealth while it meets demand for a specific product or service; to monitor and measure how the capitals change over time; and, as far as possible, to ensure that development action to improve any one of these assets does not result in the depletion of any others. Such an approach raises the importance of increasing the local ownership and control over these assets, of increasingly filling any needed-action gaps with local enterprise, and of intentionally engaging and advancing people and places on the economic margins in the process of building and strengthening value chains.
• Integrating Strategies and Systems. Bringing the different components important to economic development strategies together into more comprehensive approaches for rural and regional development is widely regarded as essential and inevitable. Integrating business-focused economic development efforts with workforce development, community development (like housing and infrastructure), social service systems, resource resiliency strategies, and civic leadership can help bring together policies and braid funding streams from federal, state, local, private and philanthropic resources; center the local priorities and needs of rural people; and lead to greater effectiveness and impact.
• Collaborating within Regions. Practical responses to the increasing complexity of the challenges that rural communities and economies face, and to the limited resources and technical capacity local governments and nonprofits have available, have led to greater collaboration across jurisdictions, organizations and sectors. This leads to sharing ideas, pooling resources, and planning joint strategies. In economic development, collaboration on regional strategies encompasses comprehensive economic development strategies, public-private partnerships, regional organizations playing new roles and expanding their toolsets, linking with universities or community colleges for workforce development partnerships, and joint efforts with utility companies and others to pursue infrastructure and investment opportunities.
• Stewarding for the Long Term. The management and use of natural resources, such as forests, forestry, fishing, farming, mining, energy and water systems, or recreation, remain at the heart of rural life. Even though most of these activities employ a small proportion of the rural workforce, collectively, they are a significant economic driver – and some, like recreation, are growing in importance. Unfortunately, prior undervaluing or despoiling of natural resources has strapped many rural places into a cycle of decline. But the impact of climate change, moves toward alternative sources of energy, and reductions in biodiversity are now showing up as important challenges for rural economic development to address, even though doing so may surface some political contentiousness. The challenges of wildfires, droughts, high temperatures, floods, hurricanes, tornadoes and rising sea levels are leading to initiatives that can both better steward natural resources and bring economic benefits to rural places, such as carbon sequestration. They are also resulting in development measures that make communities and landscapes more resilient – for example, through better land use and stronger regional food systems.
• Applying an Equity Lens. Considerations of equity in rural economic development are often confined to geographic equity – that is, fairness in the allocation of resources to rural areas in comparison with urban areas. But addressing a broader array of overlapping systemic inequities is increasingly important for rural businesses, their employees, their shareholders, and their customers, and by extension, to economic developers. The pandemic exposed inequities in the financial system, placing rural small businesses in jeopardy – especially rural minority enterprises. It also highlighted clear racial and income disparities in rural areas in terms of basic infrastructure, broadband and wealth accumulation, underlining and raising new questions about who benefits from the current prevailing economic development policies and practices.

Trends in Rural Health Care and Public Health

We conducted a scan of rural public health and health care approaches based on an extensive review of academic literature, other research and analysis, and documentation of current practices and field developments. As with our economic development scan, we found significant changes underway, some driven by shifts in public policy and others by practitioner innovation in the face of on-the-ground realities of increasing health disparities and ongoing underinvestment in rural communities. We identified six important – and growing – themes or trends.

• Engaging the Community in Design. Creating processes and structures through which community members have a voice and influence in the programs and policies that impact their lives is widely regarded as key to developing more successful efforts to achieve health and well-being. Health care and public health organizations are encouraged or required to engage systematically with their communities as part of their health promotion activities, including carrying out community health needs assessments. In rural places, community engagement can be more manageable because of smaller population sizes, greater social ties among community members, and significant (and essential) volunteer participation to carry out the functions of government — but it can sometimes be more difficult due to the geographic isolation of community members and limited resources.
• Using Data and Evidence to Drive Decision-Making. Health fields have increased their rigor in data gathering and quality reporting as part of a broader trend toward evidence-based decision-making, transparency and the implementation of value-based frameworks. For example, electronic health records track population-level trends in the access to and quality of care, as well as data on the social determinants of health. These are important for quality improvement, continued public and philanthropic investment, and regional action. But rural areas, if they are to benefit from this trend more fully, need improvements in local data technology and infrastructure, a stronger evidence base for effective rural strategies, and greater capacity in epidemiology, surveillance and population research.
• Collaborating and Integrating Services. The COVID-19 pandemic has underscored the need for integration of health, public health, and social service systems to respond to crisis and to coordinate delivery of community social services that can improve access, reduce service gaps, streamline engagement, control costs and facilitate rapid response, all while improving patient care and population health. Rural areas are increasingly piloting these models and will likely continue to do so if funding is available to support collaboration and coordination. Newer health approaches call for collaborations with economic development, environmental stewardship, law and justice, and infrastructure, although these are less common.
• Consolidating Regional and Organizational Efforts. Along with the service integration trend, regionalization and centralization are increasingly common approaches being used to address cost and efficiency in rural health, although they do not always lead to positive health outcomes. Emergency preparedness for phenomena such as pandemics and extreme weather events have certainly driven trends toward intrastate regionalization of local public health resources. For rural communities, sharing resources across jurisdictions to address complex health challenges is essential, given the reality that rural and smaller health departments provide fewer of the essential public health services. Consolidation among insurers and hospital-physician practice mergers also can create service efficiencies and strengthen market power for health care organizations, but there is no clear correlation between market power and positive health outcomes for rural communities. More evidence is needed to determine which of these models intended to increase efficiency also maximize benefits for local health and wealth.
• Expanding Local Health Workforce Assets. Although it is a more nascent trend, there is evidence that the expansion of practitioner groups of public health nurses, community health workers, and nurse practitioners is extending access to care for vulnerable and underserved areas. Such practitioner groups can provide a range of medical and nonmedical services to rural communities in both clinical and community settings. They also can play a key role in providing much-needed service integration and culturally responsive care through education, system navigation, social support, and social service support. The opportunity exists to expand these roles in rural health systems, particularly given the challenges in recruiting and retaining care providers in rural communities. But field investment in local recruitment and local or remote training and support for these positions in rural areas is lacking. In addition, some clinical medical providers view such practitioner groups as market competition.
• Pursuing Health Equity. Even before the pandemic, growing disparities existed between urban and rural public health systems, with rural areas falling further behind in quantity and quality of services available. In addition, health disparities within rural community populations have become increasingly apparent. Health equity has become a major concern, with the recognition that addressing health disparities means removing obstacles to health, including poverty, discrimination and powerlessness – along with access to good jobs and education, quality housing, and safe environments. Attention is also being paid to disparities among rural regions, as some have prospered (or at least held steady), while others have declined and suffered from hospital closures and disinvestment in public health infrastructure. In addition, significant opportunities exist in rural places to recognize how systemic inequities perpetuate specific health disparities in Native nations and how culturally grounded policies and practices can contribute to the well-being of Indigenous communities and families.

Rural Development and Rural Health: Opportunities for Alignment

Aspen CSG’s Thrive Rural Framework for equitable rural prosperity is grounded in a vision of communities and Native nations across the rural United States where everyone belongs, lives with dignity, and thrives. Achieving that vision requires alignment between the fields of economic development and health on several levels. Policymakers, intermediaries and practitioners in economic development and health must work with community members to develop a common understanding of what constitutes “success” in rural regions, economies, communities and populations – and align their strategies accordingly – to drive policy, practice, and resources towards producing those results.

Recent thinking and policy both internationally and within the United States support such an alignment. Besides U.S. examples cited earlier (like asset-building development approaches), the Organization for Economic Cooperation and Development (OECD) calls for integration of economic, social and environmental objectives in pursuing rural development policy, and the World Health Organization (WHO) defines health to include a combination of family, community, economic and social conditions, known widely as the social determinants of health. Ongoing work by scholars, funders and networks is exploring these intersections, looking, for example, at how public health, health care, community development, and personal finance can be aligned to achieve positive outcomes for families and communities. One example, the Build Healthy Places Network, focuses on building collaborations between community development and health. The Network recently released a primer for multi-sector health partnerships in rural areas and small cities. This is based on a set of principles that include community collaboration, embedded equity, integrated cross-sector partnerships, wealth creation, and long-term commitment.

With particular respect to the intersection of health services, economic development and community well-being, communities are increasingly aware of the important role hospitals and clinics play as vital anchor institutions. From 2010-2020, 138 rural hospitals (about 7 percent of the total) closed or reduced services – with at least 22 closing just since the pandemic began and 450 or more vulnerable to closure. In addition to the significant health implications these closures have for rural residents, they have local economic impacts in terms of employment, revenue flows, and business supply chains that is, according to the American Hospital Association, equivalent to $2.30 of additional economic activity for every dollar spent by a hospital.

Indeed, for many rural counties, health services are a large employer and economic generator. Even the loss of part of a hospital or health service can have severe consequences for rural economies well beyond jobs. For instance, the loss of an emergency room may drive seniors away, or the loss of an OB-GYN clinic will deter young families; and either can contribute to the downward spiral of affected rural communities. Also, workers’ compensation rates are related to the distance from an emergency room, so a closure could generate increased business operating costs and another reason a business moves away or decides not to expand.

In short, for people in rural communities, the loss of hospitals has impact and implications that go beyond weighing health care economies of scale and markets. But it is often driven by decision-makers outside the community – owners or operators of both private and public rural hospitals – making choices based primarily on health market forces without engaging the local community stakeholders. The significance of hospitals and clinics as rural economic and social anchors that provide many beneficial spillover community-building and stabilization effects may be ignored or under-appreciated, and other broader local interests discounted, when the narrow, short-term imperatives to increase profits or reduce costs take precedence for decision-makers from outside the community.

There are, therefore, clear and pressing arguments for more integrated approaches between the fields of economic development and health. Imagine what contributions to long-term rural community stability, resilience and prosperity might flow from aligning their efforts. Actions in the economic development sphere might include increasing the affordability and availability of reliable, high-speed broadband; robust workforce programs for rural public health nurses, community health workers, and nurse practitioners; and the integration of local leadership in setting priorities and making decisions. Actions in the health sphere might lead to innovations in integrated rural health care, expanded telehealth, distributed care networks, expanded measures of success used by the health care field, and regional purchase agreements that support local businesses and minority entrepreneurs.

Such alignments could amplify the positive trends described here. But for rural communities to truly benefit from intersecting efforts, policymakers, intermediaries and practitioners must continuously ask themselves if those efforts truly eliminate barriers to building healthy communities and economies across place, race and class. How might policies or practices benefit or harm varying population groups, or different communities in the same region? How can policies and practices be designed to improve outcomes for those who – whether unintentionally or intentionally – have been historically overlooked or exploited? Who is represented at and has a vote at decision-making tables? What are the likely unintended consequences across populations?

Three overarching opportunities for action across fields can help accelerate trends at the intersection of economic development and health. Importantly, the pursuit of any of these should include thoughtful analysis of the aforementioned questions. These opportunities include:

• Focus on measuring rural well-being as improvements in multiple community and regional assets.
  Newer frameworks with expanded definitions of wealth and health can make two important contributions. First, they can provide a means of determining progress towards community goals across a range of indicators that measure the vitality and robustness of a place’s natural, built, financial and cultural assets, as well as the ideas, skills, relationships, health and influence over decision-making resident in a community’s people and organizations. Second, they can help to assess the impact of a significant change in the community in terms of impact on the full range of community and regional assets. Policymakers, intermediaries and practitioners in economic development and health, as well as in allied fields such as community development, social services, transportation, land use, housing and environmental protection, can use such frameworks to work directly with community members and explore synergies, opportunities and potential areas of conflict – and to drive the quest for more equitable rural development.

• Integrate and collaborate to improve multiple cross-field outcomes.
  A continuing challenge for rural communities is the issue-siloed and usage-limited structure of policies, programs and funding streams made available by federal, state and local governments; the private sector; and philanthropy. When rural regions and communities are already struggling with limited financial resources and technical capacity, having to navigate the complexity of multiple and often conflicting requirements to access multiple streams of siloed program support to address a more comprehensive, cross-issue local challenge can be a bridge too far. Two lines of attack are required. The first is to advocate for flexible, integrated funding streams that encourage and support projects with multiple objectives across economic development and health and connect these funding streams to outcomes outlined in newer frameworks. The second is to encourage local and regional collaborations across jurisdictions, organizations and functions to share ideas, pool resources, and plan together. Hospitals and clinics, as well as community colleges, community foundations, councils of government, electric cooperatives, community development financial institutions and other regional intermediaries can all act as rural action hubs – anchors, conveners and coordinators to advance community and regional goals. These rural action hubs can also help build the civic infrastructure to engage those whose well-being will be most significantly affected by resource and design decisions, along with those who have been historically marginalized and isolated from decision-making circles.

• Strengthen a shared data and evidence infrastructure and usage to drive cohering strategies.
  Being able to gather data and evidence on conditions in rural communities is essential for most public services and functions, to ensure that services are delivered where they are needed, to better understand what is resulting from service and program efforts, and to assess which policy, practice and systems changes are working or needed. This is critical to health care and public health operations with their emphasis on data-driven and evidence-informed decision-making. Economic and community developers and planners also rely on data and geo-spatial intelligence to track changes in the economy; the welfare of local businesses and current and aspiring workers; the demand for land, housing and transportation; shifts in demographics; and the availability of capital for investment. Subject to the usual privacy and data security safeguards, closer integration of data and analytic capabilities may lead to more accurate and nuanced understanding of challenges and opportunities. Importantly, data collection and evidence-building have not always sufficiently or fairly represented diverse perspectives and cultures. Advancing this opportunity requires exploring how to expand data and evidence to be representative of and relevant across the diversity of rural communities, economies and populations. These would be particularly helpful in the preparation of community health needs assessments, comprehensive economic development strategies, and other regional and community planning activities. Strengthening shared data and information infrastructures in rural regions can help lay the groundwork for more cohesive cross-sectoral strategies and more effective implementation.