Abstract
This paper examines the concept of democratic local governance and its relevance for health development in Central America, a region which was torn apart by conflict in the 1980s. Peace-building has been taking place since the 1990s in a difficult macro-level context, as stabilization and structural adjustment policies in the postwar period have led to drastic state reforms with high social costs for the marginalized population. Innovative experiences and strategies in health have also developed in the region over the last decades, based upon local participatory governance, contributions to public health policy, development and peace-building at the local level. This article describes two of these municipal health development processes, the SILOS (Local Health Systems) in the northern zone of San Salvador, El Salvador and the municipal health process in León, Nicaragua. The paper examines the relevance and sustainability of these local initiatives and the importance of democratic local governance for (health) development. It also analyzes the extent to which macro-level reform policies have enabled the development of these processes and the perspective for sustainability of democratic local governance in countries confronted by serious lack of governability. Whilst the imperative for reform/change is beyond doubt, as well as the advances booked in terms of local democratic governance and health, the authors underline the need to address the incoherence in global reform policies and - in the current situation - the impossibility of achieving democratic governance and equity in health within the confines of the city. Finally, the authors question the relevance of a development paradigm that does not address democratic local governance and existing structural (political, social, economic) inequalities.