Telemedicine has been used for some years in the industrialized world, albeit with rather mixed success. There is also a considerable literature on the potential use of telemedicine for the developing world. However, there are few reports of the actual use of telemedicine there. A review identified five telemedicine networks providing second opinions; each network had been in operation for over five years. Although they have different aims and methods of operation, they exhibit some common features. In particular, none of them appear to be dealing with markedly increasing referral rates. Rough calculations suggest that only about 0.1% of the potential telemedicine demand from the developing world is being met. Possible reasons include the referrers being too busy and a perceived loss of control. If this analysis is correct, then the right strategy for future telemedicine in developing countries will be to concentrate on the construction of within-country networks that demonstrably alter health outcomes, can be shown to be cost-effective and sustainable, and will provide a model for other countries to copy.