Democratic governance - fairytale or real perspective? Lessons from Central America

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.

Integrated Approaches to Address the Social Determinants of Health for Reducing Health Inequity

“…Political will is sadly often limited 8 , 34. Despite the rhetoric about commitment to public participation, and progressive legislative frameworks, in reality participation is often manipulated, found lacking, or even aborted 35 , 36…”

Limits to adaptation to interacting global change risks among smallholder rice farmers in Northwest Costa Rica

“…The Province also faces a number of interlinked rural development challenges including widespread poverty and food insecurity (Barten, Montiel, Espinoza, & Morales, 2002). To address these challenges, the Costa Rican government initiated the Arenal-Tempisque Irrigation Project (Proyecto de Riego ArenalTempisque, PRAT) in 1983.…”

Emerging Strategies for Healthy Urban Governance

“…Good national and international governance can be a source of norms, and a recourse for those excluded from local decision making 55. National governments provide the “policy environment” in which local government and governance can innovate, or not 58,59. It is not even clear that empowering urban areas leads to greater attention to urban inequities: “Although central governments are unlikely to be generally more ‘pro-poor’ than local governments, it may be easier for central governments to insist on pro-poor use of grant resources than for local governments to use their own resources in that way.”14(p 14)…”

“…Investment is also necessary to sustain and build on success. Even successful models of participatory governance—and there are many—remain “feel good” stories for researchers, governments and NGOs unless they can be replicated at a sufficient scale to influence the condition of the mass of urbanites 58,61. International funders and governments speak about the importance of good governance and strong civil society, but investment in general governance capacity, unlinked to a particular categorical program or specific objective, is still too rare.…”