What eleven specialists can do if you let them move
Eleven paediatric neurologists. Fourteen million children. A mobile phone and a quarterly visit.
There is a number I keep returning to from a paper we recently published in Frontiers in Health Services.
At the time the programme I am about to describe began, Myanmar had eleven paediatric neurologists. Eleven, for a paediatric population of around fourteen million children, the vast majority living outside the countries largest city, Yangon. This, in a country where 70% of the population is rural and the roads between them and any kind of specialist care are long.
Eleven.
A single large children’s hospital in London employs more than that.
The conventional response to a workforce gap of that scale is a training plan. Produce more specialists and build more capacity at the centre with efforts to extend the referral network. These approaches are not wrong, but they take decades and the children in Kale and Kengtung and Myitkyina do not have decades.
So what do you actually do with eleven specialists and a country the size of France?
The answer, in this case, was deceptively simple. A hub-and-spoke model linking the paediatric neurology team at Yangon Children’s Hospital with general paediatricians in seven regional public hospitals.
Quarterly in-person clinics, where specialists travel to the patients’ local hospital. Monthly virtual consultations in between and a mobile messaging group for quick questions.
The neurologist goes to the child. Not the other way around.
This sounds really obvious, and it really isn’t.
The default assumption of specialist medical care, in low-resource settings as much as anywhere else — is that specialist expertise lives at the centre and patients travel to reach it. That assumption is so embedded in how all health systems are funded and organised that it rarely gets questioned.
The problem is that in Myanmar, for parents of children with a neurological diagnosis, the journey to Yangon is not so much an inconvenience as a financial event. Our cost analysis compared the cost per patient of attending a specialist appointment at the tertiary centre in Yangon with that of running an outreach clinic at their local hospital (Linn et al., 2026).
Under the standard referral model, the mean cost per patient consultation was $193 US dollars. Under the new outreach model, it was a more manageable $ 7 per patient.
For hospitals the very furthest from Yangon, Kengtung in the east, Myitkyina in the north the standard referral cost reached $441 per consultation. The outreach visit cost $29 and $8 respectively. The cost saving ranged from 81% to 98% depending on location.
In a country where many rural families live close to subsistence, $441 is months of household income. And the comparison assumes families could make the journey at all. Before the programme, most of them couldn’t and so the reality was not expensive referrals to Yangon, it was no referral.
Rather crucially, the cost of the specialist visits to district hosptials was covered by the Ministry of Health and Sports, reducing the costs to families to nearly zero.
Between 2017 and 2020, the programme facilitated 2,603 patient consultations across the seven regional hospitals. Epilepsy was the most common diagnosis at 54%, followed by cerebral palsy at 12%. Attendance rose steadily and consistently across the period. This was not the ebb and flow of a new initiative, but genuine building demand as families learned that a specialist would actually come.
The diagnostic profile is important as Epilepsy and cerebral palsy are not acute presentations. They are conditions requiring careful management across childhood: repeated follow-up, medication titration, monitoring of development over time. They are also, in low-resource settings, among the most undertreated conditions precisely because of that burden of access. Evidence from population-based studies in Myanmar showed a wide treatment gap for childhood epilepsy, with children remaining undiagnosed, untreated, or managed on inappropriate regimens. The outreach model did not just provide access, it provided the kind of access these conditions actually require.
The telemedicine element is worth examining separately, because it was not telemedicine in the conventional sense.
Rather than the standard model of doctor-to-patient interaction over a video platform, the approach incorporated a non-specialist doctor at the patient’s end who would conduct the physical examination under real-time instruction from the specialist in Yangon. The regional paediatrician became the hands, eyes and ears. The neurologist became the clinical reasoning. Between visits, cases were triaged through the messaging group; regional hospitals eventually began pre-screening patients so that specialist time during outreach visits focused on the children with greatest needs.
The standard critique of telemedicine in specialist care is that it cannot replace physical examination, which is true. The response this model developed was not to abandon physical examination but to restructure who conducts it.
It is not a perfect solution. Access to diagnostics and key medications varied across hospitals. Reliable internet was not guaranteed. The neurology team in Yangon was doing this alongside their full clinical duties. There is a ceiling at which this model becomes non-viable. We could not identify exactly where that ceiling was during the evaluation period, which tells you something, but it exists.
Then 2021 happened.
The coup dismantled the health system the programme had spent four years embedding itself within. The hospitals remained, but the Ministry of Health and Sports they reported to was controlled by a military junta rather than a democratically elected government.
I say this not to end on defeat, unlike last weeks post, this programme worked. The numbers are real: 2,603 consultations, $7 per patient, cost savings of up to 98%. Those children were seen who would not otherwise have been seen. The evidence is published and available to health systems facing similar constraints, which is most of them.
The broader argument the model makes is one that global health absorbs slowly: specialist scarcity is as much a distribution problem as a supply problem.
More than 70% of countries classified as low-income lack consultant-led paediatric neurology services across all regions. The response is almost always framed as a training question, we must produce more specialists goes the cry. But it does almost nothing in the short or medium term for the child with epilepsy in Kale whose family cannot afford the journey to Yangon.
What this programme demonstrated is that a small number of specialists, a quarterly schedule, a mobile phone, and a genuine willingness to redesign who travels where can reach a significant number of those children.
No new technology, no large external budget, no international volunteers.
Existing capacity, organised differently.
This was not a resource problem solved by more resources. It was a distribution problem solved by a quarterly visit, a messaging group, and a willingness to question which direction the specialist should move.