<p>Healthcare providers have been encouraged to become entrepreneurs to fill a widening service gap in depleted rural areas. This paper explores how these entrepreneurs add value, finding a complex multidimensional process of value creation in rural healthcare. Taking a grounded approach, 40 health entrepreneurs were interviewed across the health settings of four European countries characterised by ‘mixed’ public–private healthcare. Through an institutional logic framing, the paper builds a novel process theory of value creation in a rural socio-spatial context. It identifies value creation elements, effects and diverging institutional logics characterised by polysemy and polyphony. Overlaid on the bio-physical layer, areas of healthcare value creation hybridity are identified, with implications for the resilience of rural communities and sustainability of rural healthcare enterprises. By presenting an agent-relative and pluralistic theory of rural healthcare entrepreneurship, the paper adds an understanding of multidimensional value creation and contributes to entrepreneurial context and everyday entrepreneurship debates. </p>