Under what conditions do local political elites in new democracies promote citizen health? To address the question, this paper advances hypotheses grounded in prominent political science debates and assesses them against comprehensive, granular data from the most recent South African national census. The evidence rejects the hypotheses that relatively great partisan competition and relatively great popular participation boost local population health. The evidence provides conditional support for the hypotheses that local health outcomes are enhanced in municipalities where the national ruling party commands relatively great citizen backing and where hereditary chiefs are strong. In particular, where local strongholds of the national ruling party coincide with strong chiefly authority, the predicted probability of infant and under-five death over all households is reduced, as is the predicted probability of infant and under-five death among majority Black African households, holding other things equal. In these nuanced ways, the actors holding power at the local level matter for the survival of babies and children in South Africa. The paper contributes to scholarship on institutions in new democracies, chiefly authority, the conditions for infant and under-five survival, and the political determinants of health. In doing so, it demonstrates the value of drilling down to the local level to probe the political determinants of population health.