Leading at the Frontlines of Rural Healthcare

A new year invites reflection. What should we carry forward? What needs to change? And what kind of leadership does this moment require of us?

As we step into 2026, I keep coming back to one issue that deserves deeper attention: rural primary healthcare. Not just the work of hospitals, but the essential role of community health centers, free and charitable clinics, and nonprofit organizations. These groups are quietly, steadfastly serving patients, regardless of a patient's ability to pay, in areas where longstanding barriers to access continue to grow.

Last week, I spent time with frontline health providers in Hawai'i, many of whom were born and raised there and continue to live this reality every day. Few, if any, alternatives for healthcare exist in many communities across the islands - especially for Native Hawaiians. What I heard went far beyond staffing shortages or infrastructure challenges. Again and again, the conversation returned to the commitment, resolve, and creativity it takes to build primary healthcare systems that work when operating conditions are challenging.

Hawai'i as a Lens on Rural Health Care

Across rural areas, distance defines what care can be accessed in ways many people never have to consider, from long drives for routine appointments to limited specialty services. Nearly 20 percent of Americans live in rural areas, according to the National Association of Community Health Centers, and these communities face persistent provider shortages, hospital closures, and significantly greater travel distances to receive care. Since 2005, nearly 150 rural hospitals have closed, turning access into a daily struggle for millions of families.

In these settings, primary care providers often become far more than a "family doctor." They serve as the care coordinator and, in many cases, the closest thing to a specialist their patients can access. Community health centers and free clinics step in to fill these gaps as best they can, managing complex conditions, navigating referrals, and stretching limited resources to keep people connected to care. They provide culturally appropriate care that respects their patients' unique heritage, language, and ancestral diet or medicine.

I also met nonprofit partners who step in when existing services are under strain, or patient needs are unable to be met by traditional systems. Organizations like Healthy Mothers Healthy Babies Coalition of Hawai'i, working to ensure families have access to prenatal care, education, and support during some of the most vulnerable moments of their lives. These gap-filling organizations play a critical role, especially in communities where options are limited and needs are high.

The providers and staff I met in Hawai'i go far beyond job descriptions, not because it is easy, but because their patients depend on them.

That is why primary care matters so deeply. It is the foundation of everything else. Strong primary care keeps people healthier, catches problems earlier, and reduces the need for emergency and specialty care that may be hours away.

What I saw on the islands mirrors similar health challenges experienced in rural communities, from Appalachia and the Mississippi Delta to rural Alaska, Tribal lands, and pockets of the Midwest. The communities are unique, but the practical constraints are remarkably similar. Clinician shortages, missed appointments due to lack of transportation, and high levels of noncommunicable disease are common.

On the Big Island, some communities have no pharmacy within 80 or 90 miles. Broadband internet is unreliable. Electricity - which in Hawai'i costs far more than in any other state - regularly goes out, resulting in clinic shut-downs, spoiled vaccines, and cancelled appointments. Healthcare pauses not because people stop caring, but because systems fail them.

One physician described making urgent transport decisions in the middle of storms, weighing whether a pregnant patient could safely stay or needed to be airlifted to another island. Expectant mothers with complications often must board inter-island transfer flights alone, leaving partners and children behind and hoping everything will be okay. These are not abstract decisions. They are deeply human ones that stay with you.

The Workforce Reality

NACHC reports that approximately 70 percent of rural communities are federally designated Health Professional Shortage Areas, with an estimated shortfall of 20,000 primary medical, dental, and mental health providers nationwide.

Hawai'i faces a chronic shortage of physicians due in part to its unique geography - specialists cannot easily be shared across the islands - and pay scales that are not commensurate with the very high cost of living. The gap between need and capacity continues to widen, placing even more pressure on the providers who remain.

How Communities Are Responding

What stayed with me most from my time in Hawai'i was the dedication and response of health staff and providers.

I met teams bringing healthcare into schools so parents don't have to miss work. Mobile health units delivering care to the most remote valleys. Outreach teams showing up week after week for people experiencing homelessness. Providers who know families across generations and who continue to build trust one visit at a time.

One moment in particular stood out. A child struggling in their elementary school classroom was screened through a school-based clinic. A hearing issue was identified. Following treatment, the student's grades immediately improved, and behavior shifted. A future opened, simply because providers met the child where they already were.

This is what effective systems look like. Practical. Preventive. Deeply rooted in community.

Growing Our Own, Strengthening Communities

Another theme surfaced everywhere I went. Workforce pipelines matter.

Leaders are building pathways for local students to become community health workers, medical assistants, nurses, and social workers, creating opportunities to train where they live. Care is most effective when delivered by people who belong to the communities they serve, individuals who share lived experiences, speak the same language, and understand patients' realities firsthand.

NACHC notes that rural community health centers are actively training the next generation of providers, including more than 3,200 physicians, 2,000 nurses, and 1,600 medical assistants through programs like the ones we heard about on Oahu. Traveling providers can provide temporary capacity but growing your own builds a future. This is not just workforce development. It is long-term system design.

What Leadership Looks Like Now

What I saw in Hawai'i reinforced my belief that no single organization can solve these challenges alone.

What guides our work at Direct Relief is a simple belief: it's the people closest to the challenge who know the solutions best. Our role is to support their leadership, strengthen the systems they depend on, and show up as partners who are in it for the long haul.

That includes investing in power resiliency. Across Hawai'i, Direct Relief is helping fund solar and battery backup systems at clinics and health centers so care does not stop when the grid goes down. For patients who rely on refrigerated medications, oxygen, dialysis, or prenatal monitoring, uninterrupted power is not a convenience. It is a lifeline. These systems allow providers to keep doors open, vaccines cold, and care moving forward, even during outages and storms.

This visit will continue to stay with me because it reflects the kind of leadership I believe in. Leadership that is steady, deeply engaged for the long term, and focused on solving real problems. Leadership that does not wait for perfect conditions, but moves forward with what is available, guided by purpose and partnership.

The future of rural healthcare will not be shaped by one organization or one policy. It will be shaped by thousands of leaders, clinicians, and community members who choose, day after day, to serve and care for one another.

-Amy

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