In the early 1990s, Cameroon implemented a decentralised health system in accordance with the health district and primary healthcare frameworks recommended by the Africa Regional Office of the World Health Organization (AFRO-WHO). To enhance both responsiveness and equity and to foster participation in the financing and management of the district health system, community dialogue structures were established as governing bodies. Such participatory governance was intended to elicit the views of stakeholders (bureaucrats, health development promoters, community representatives, healthcare providers and patients), and to improve accountability and to strengthen district health systems in order to achieve better health status for the population. During the mid-term evaluation of the 2001-10 Health Sector Strategy (HSS), stakeholders expressed dissatisfaction and identified poor governance and weak health district development as major reasons for Cameroon being unable to achieve its health-related Millennium Development Goals. Several underlying factors were identified for the failure to effectively implement the recommended changes within the framework of health decentralization reforms. Accordingly, recommendations were made for the improvement of district development governance as a key priority for the revised 2001-2015 HSS. The Technical Secretariat of the Steering and Follow-up Committee for the Implementation of the HSS asked the Centre for Development of Best Practices in Health (CDBPH) to summarise the available evidence.