Rural Public Health Systems Discourse – Ongoing Challenges, Few Solutions

Given the shortage of workers in today’s post-COVID economy, all LHDs—urban and rural—are facing workforce gaps and finding it hard to recruit staff. However, the challenges to rural LHDs are compounded by their being under-funded.

Several years ago, when my friend had to be taken by air ambulance from North Dakota to Minneapolis to get prompt treatment for severe frost bite, I realized the stark contrast between the world I grew up in – one of the biggest and most densely populated metropolitan cities in the world, where everything from groceries to “spa days” can be home-delivered – and the world that was to become my research focus –rural and frontier areas in the US. The incident sparked my curiosity to understand why basic resources and services we take for granted in cities are not as easily available in rural areas, even if people were willing to pay for them.

Today 1 in 5 Americans (or 65 million residents) live in rural America. Rural America is fundamentally different from urban centers. Rural residents tend to be older, poorer, and more resource constrained. They have limited access to different types of infrastructure (such as broadband Internet, grocery stores), as well as fewer educational and employment opportunities. Not surprisingly, they experience worse health outcomes than their urban counterparts at an individual level.

Most readers may not be surprised to hear about limited access to private/clinical health care resources in rural America, but there are some rural areas that are not even served by local governmental public health departments (LHDs). In addition to the resource constraints from existing in poorer communities, rural LHDs face unique challenges from a systems perspective. Historically in the US, county health departments were established with foundation support. When the threat of communicable diseases in rural areas was recognized, rural LHDs got some governmental funding, but with the decline of that threat, governmental funding decreased, and they needed to rely on clinical fee-for-service programs. In medically underserved communities, LHDs providing clinical services fill in a gap in the health care system, but doing so often takes away from their capacity to perform foundational public health functions such as disease surveillance and community health needs assessments.

In terms of staffing also, rural LHDs are at a disadvantage. According to a 2019 survey, only 50% of leadership at rural LHDs had a graduate degree as compared to 76% in urban LHDs. Rural LHDs still continue to rely heavily on public health nurses for staffing. Compared to 16% in urban areas, 33% of leadership positions in rural LHDs were held by clinically trained nurses, indicating that rural LHDs lack staff who are trained for non-clinical population-based roles, such as strategic planning and population assessments. In addition, changing demographic profiles in rural areas mean that LHDs would benefit from more diverse staff to reflect new communities they serve.

Given the shortage of workers in today’s post-COVID economy, all LHDs—urban and rural—are facing workforce gaps and finding it hard to recruit staff. However, the challenges to rural LHDs are compounded by their being under-funded. They do not have the budgets to offer competitive salaries or create additional positions, they cannot afford to pay salaries expected by those with higher educational qualifications, and they have trouble convincing new staff to relocate to communities that they perceive as not “livable” or having little opportunity (in actuality, rural counties have attributes that they can leverage to attract not just public health workforce but new residents in general – lower cost of living, higher levels of social capital and cohesiveness, and a slower and less stressful pace of life). 

How should rural communities market themselves to prevent net population loss? How do we create viable and resilient rural communities? Are healthy rural communities a public good that benefit both rural residents and city-dwellers and the country at large? How do we allocate or reallocate resources to subsidize rural LHDs so they can do critical work? These challenges are not new – they have been identified in the past and discussed every few years – but we are still in need of solutions sustainable in the long term.

Author Profile

Harshada Karnik
Dr. Karnik is a researcher at the Center for Public Health Systems at the University of Minnesota. Her research interests include public health workforce, food and governmental health systems, program evaluation, rural / community development, and health equity. She holds a PhD in applied economics and master’s in public policy from the University of Minnesota.