Background <p>While telemedicine has become an established component of healthcare delivery globally, challenges to scaling emerging initiatives persist across multiple levels. Over the last 5 years, our team has developed a pediatric telemedicine and medication delivery service (TMDS) in Haiti that integrates clinical guidance with rapid access to medications. Building on successful proof-of-concept studies, we are now well positioned to characterize both general challenges to telemedicine scale-up and those unique to the TMDS model.</p> Methods <p>In this descriptive qualitative study, we conducted focus group discussions and administered written questionaries to TMDS staff, including physicians, nurses, and medication delivery drivers. These qualitative survey instruments were designed to capture staff experiences and suggestions. Using framework matrix analysis, we identified key challenges and opportunities associated with the TMDS model.</p> Results <p>Fourteen nurses, 13 drivers, and 3 on-call physicians participated in the study. Areas for improvement related to obtaining quality information from virtual exams, the reliability of technology and communication infrastructure, conditions necessary for effective in-person exams, the limited scope of the TMDS workflow and clinical resources, and uncertainty surrounding long-term sustainability. These insights informed the development of targeted potential solutions categorized into three domains: cognitive, physical and mission-oriented.</p> Conclusion <p>The findings will guide our internal scale-up strategy and may offer guidance to similar telemedicine initiatives.</p>