This paper provides a synthesis of the main issues discussed at a conference (International Conference on Integrated Water Resource Management (IWRM) entitled: Lessons from Implementation in Developing Countries which took place from 10 to 12 March 2008 in Cape Town, South Africa, at the Cape Town International Convention Centre), which was coordinated to share experiences and lessons learned on the implementation of IWRM in developing countries. This paper discusses six themes that emerged from the conference. These themes provide a perspective on the current status of IWRM and assist in formulating the agenda for further research and implementation approaches based on lessons learned. Firstly, although there is considerable history and international acceptance of IWRM, there is still ongoing debate on how IWRM is defined. However, aside from these debates there is general agreement on the principles underlying IWRM and the potential it holds for managing complex systems that cannot be adequately achieved through the single-sector management approach of the past. To overcome past management paradigms, new capacity building approaches are required. Secondly, implementation of IWRM requires a balance between policy and institutional support and community level projects that have small-scale tangible results for the poor. Thirdly, IWRM involves integration across many spheres, specifically the integration of groundwater management into long-term water resource planning. Fourthly, although there is general endorsement of the importance of public engagement in supporting IWRM approaches, effective public engagement requires considerable strategic planning to ensure that efforts are both applicable and relevant to those involved. Fifthly, the conference highlighted the importance of developing appropriate economic methods and instruments to address the economic trade-offs and decisions that are apparent in water management. Finally, appropriate data, information systems and indicators are required to adequately monitor progress with IWRM implementation.