The poor governance in Cameroonian health districts stems from a lack of clear and consistent operating procedures for district governing bodies and health services, power imbalance between district managers and community representatives, and insufficient knowledge of the existing legal and regulatory frameworks. In addition, district management teams and community members lack skilled individuals who are able to lead the health decentralisation reform. Mechanisms and tools to ensure the appropriate use of information in the planning process, to ensure effective participation, and to enforce transparency and accountability on a district level are inadequate. Finally, incentives and resources for the implementation of the participatory governance embodied by the national health policy are inadequate.