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Background: The purpose of this paper is to explore the underlying challenges in the telehealth environment in India and Pakistan that impede the delivery of high-quality images between a patient and health care professional. Method: An exploratory study was conducted among healthcare professionals in India and Pakistan to assess their perceptions regarding image quality, which is used for the diagnosis and treatment decision making. This cross-sectional qualitative study used semi-structured interviews with healthcare professionals in both India and Pakistan. Results: The interviews were analyzed using a thematic analysis, which revealed three major themes. These themes being: ICT infrastructure and connectivity, expertise of persons taking images, and multiple transmission degrading image quality. Conclusions: Findings indicate that in both countries, the main underlying challenge is the lack of consistency in the network infrastructure between urban, rural and remote areas. Additionally, training patients to use hand-held devices to take high-quality images could hold the key to improving the reliability and, consequently, the quality of images transmitted between patients and health care professionals. [ABSTRACT FROM AUTHOR]