On September 8 2000, world leaders gathered at the United Nations summit and resolved to help citizens in the world's poorest countries to achieve a better life by the year 2015. This resolve was outlined in the Millennium Development Goals that were subsequently published with goals 4, 5 and 6 specific to healthcare. The integration of ICT‘s in the remote delivery of services has opened new avenues from which centralised, scarce resources can be accessed remotely for the benefit of the general population. Telemedicine has made great strides in the developed world with remote populations benefiting from the improved access to healthcare. In the Eastern Cape Province of South Africa, the sub-field of teleradiology has shown promise for enabling the wider delivery of specialist services. However, in resource constrained settings such as developing countries, telemedicine has had limited success and as a result, the equitable access to healthcare for remote populations remains inconceivable. This is exacerbated by the migration of healthcare professionals both domestically and internationally. The public sector has suffered the most with acute staff shortages in the public healthcare institutions, more so in rural and remote areas. This study identifies the prevailing challenges posing as barriers to the effective use of telemedicine services in the Public health sector in resource constrained settings and provides recommendations and guidelines aimed at facilitating the adoption and effective use of telemedicine. Challenges are identified from literature and from the first person accounts of specific role-players who are directly involved with telemedicine in their respective institutions. Participants are drawn from institutions offering telemedicine services within the Eastern Cape Province of South Africa. Challenges identified from literature are collated with those identified from the participant interviews to provide a concise list of factors that is used as input to the recommendation and guideline development process. The results thus far point to an enthusiastic environment coupled with a semi-capable infrastructure but however hampered by staff shortages and a general lack of support structures and propulsion mechanisms to adequately encourage the wider use of telemedicine. The proposed guidelines aim to address the challenges at the different role-player levels.