The paper reviews the role of Small and Medium Size Enterprises (SMEs) as drivers of employment and economic growth in rural regions across a number of OECD geographies. It argues that SME creation is especially important for rural economic development and identified lessons for national level policy that can help strengthen the performance of SMEs and enhance the creation of new SMEs. This working paper focuses on four cases studies in Atlantic Canada, Quebec, Scotland and the United States to derive general findings and recommendations.