Managing proximity care in rural areas: an action research study on four interdependent managerial challenges

Background. The reorganisation of territorial healthcare after the COVID-19 pandemic has placed proximity at the centre of health-system reform, formalised in Italy by Ministerial Decree 77/2022. Yet the standard organisational templates promoted by national policy lose traction in rural areas, where low population density, geographic dispersion, ageing and depopulating communities, and persistent workforce shortages generate a distinctive set of managerial problems. The managerial dimensions of proximity generation in rural settings [IL1.1]remain comparatively under-examined. Methods. The study adopts an action research design involving nine Italian public healthcare organisations operating in areas with significant rural connotation. Through iterative cycles of organisation-level preparatory work, cross-site plenary workshops, and analytical consolidation, and through cross-case thematic analysis, this paper reconstructs the managerial reasoning through which participating organisations articulate proximity care in their rural territories. Results. Cross-site analysis identified four interdependent managerial challenges: knowing rural communities through granular situational analysis; building a participatory vision of health generation; designing flexible and integrated organisational solutions; and investing in the enabling factors of change. The four challenges are systemically interdependent rather than sequential, and the community is best understood as an extended institutional ecosystem in which the responsibility for health generation is distributed across public institutional actors, health and social professionals, third-sector organisations, and service users themselves. Conclusions. Proximity care in rural areas is generated through sustained organisational practice, underpinned by dedicated roles, mechanisms, and routines calibrated on all components of the extended community, rather than through episodic engagement with any single category of actors. The findings offer practical guidance for healthcare managers, public institutional partners, and third-sector actors engaged in operationalising proximity-oriented reforms.