Introduction:Many countries report difficulties in preserving access to care in rural areas. This paper examines how hard-to-serve regions sustain care provision by transforming service delivery into population health systems.Theory and methods:The paper builds on theory on care delivery in hard-to-serve regions. It presents a qualitative case study from the Lower Engadin, a rural high mountain valley in the Swiss Alps. Data sources include semi-structured interviews, participant observations, and documents. Data are analysed using recent conceptual research on population health systems.Results:The case study illustrates how politicians and providers in the Lower Engadin resolved a care crisis and preserved access to care by forming a population health system. The system is organised around the Healthcare Centre Lower Engadin. Citizen-centred interventions target an aging population and include health promotion and prevention programs as well as case management based on an ambulatory-before-inpatient care strategy.Conclusion:Hard-to-serve regions like the Lower Engadin preserve access to care by reorganising service delivery towards population health systems. The paper contributes to research on population health systems and care provision in rural areas.