Background: Performance-based financing (PBF) is a healthcare reform that is widely adopted in low- and middle-income countries (LMICs). PBF is an intervention designed to strengthen healthcare systems in LMICs. It represents a fundamental shift towards improving healthcare amongst the most vulnerable, with a focus on maternal and child health services. Broadly, there are gaps regarding PBF’s effect on healthcare systems and various aspect of healthcare, including efforts to implement universal healthcare coverage. PBF introduced an innovative component—the PBF equity instrument—geared towards achieving universal health coverage. The effect of this equity instrument has not been studied. There is significant gap regarding how it is defined and implemented in various context. Cameroon has one of the highest maternal mortality rates in sub–Saharan Africa and with high out-of-pocket expenses that impede access to maternal health services. PBF was introduced in Cameroon in 2012 with a focus on maternal health services and was adopted in 2017 as a national strategy towards achieving universal coverage, however, the definition and implementation of the PBF equity elements remain a gap in Cameroon and sub-Saharan Africa. This dissertation is focused on studying the PBF equity elements in Cameroon in order to get a broader perspective on the effect of the PBF equity elements as a policy tool in improving the lives of the most vulnerable population to ensure no one is left behind in the efforts towards achieving universal health coverage. Objectives: This dissertation aimed (1) to investigate and characterize the effect of the PBF equity elements in improving equity in access to selected maternal services (2) to understand how the equity elements is defined and implemented in Cameroon; and (3) to generate a framework that will facilitate the identification of gaps and challenges, in turn informing policy development that is relevant to PBF equity elements in Cameroon and PBF research on equity in other countries; and (4) to explore health providers experiences before and after the introduction of PBF in Cameroon. Methods: This dissertation employed a mixed methods approach to address the above objectives, involving the use of multiple frameworks and triangulation across and within objectives. First, to investigate the effect of PBF on equity in improving access to maternal services, I designed a systematic review with a focus on one of the equity elements—subsidizing user fees to reduce out-of-pocket expenses to improve access to maternal health services. The aim was to get a broader overview of the PBF equity element and to understand the effect of PBF on out-of-pocket expenses in improving access to selected maternal health services in sub–Saharan Africa. Second, I narrowed the assessment to a specific context-Cameroon. Given the heterogenous nature of care delivery in Cameroon, I investigated the effect of PBF on out-of-pocket expenses in improving access to selected maternal health services across healthcare sectors using a before-and-after study design. The rationale was to address the limitations of an earlier PBF impact evaluation in Cameroon, in particular, potential heterogeneity across settings and sectors which had not been considered. Third, to describe and define the implementation of the PBF equity elements in Cameroon, I conducted a grounded theory study -given that it is a new policy that has not been well studied -to understand the social processes and actions from health facilities, health providers, PBF managers and the community, and generated a theoretical framework to inform the challenges and gaps in the implementation process. Finally, as a newly adopted health reform, I conducted an in-depth qualitative study to understand the experiences of health care provides before -and-after the implementation of PBF and its equity elements and the potential for sustainability of the policy especially the equity strategies in Cameroon. Findings: The findings provide an overarching understanding on the effect of one of the PBF equity elements in improving access to maternal health services in sub–Saharan Africa, and in particular, an understanding of the effect of the PBF equity elements in improving access and utilization of selected maternal services in Cameroon. At the health system level, the findings provide an understanding of the focus of the equity elements within the context of Cameroon and further insight on the gaps and limitations in the implementation of the PBF equity elements and the potential challenges in sustainability towards achieving universal health coverage. At the health facility level, it provides an understanding on how the PBF equity elements is understood, defined, and implemented and provides directions on the challenges to inform policy and to guide research. At the individual level, it provides an overview of the expectations of health care providers from a supply side perspective and the potential effect it has on demand creation from women and households in improving access to maternal health services. Overall, the findings provide insight on how the equity elements are defined and implemented but also provides opportunity and areas of improvement and detailed how PBF equity elements can be further assessed and how delays in payment of PBF incentives can potentially affect the realization of the equity elements in improving access and utilization of maternal health services amongst the poor and vulnerable. Conclusion: Equity is central and essential to the delivery of services to achieve universal health coverage. The adoption of PBF in Cameroon is a step toward achieving universal health coverage with the recognition that universal health coverage cannot be effectively implemented in an institution without good governance. The PBF initiative is viewed as an entry point for universal health coverage, in order to evaluate the level of preparedness of health facilities to embrace universal health coverage in terms of quality of health care, production, good managerial skills, and financial management. However, due to administrative bottlenecks, the government has yet to accept some of the established principles of PBF—this in turn causes delays in payment and this hampers the effective implementation of some of the PBF equity strategies. Therefore, though PBF is a national policy, the actors at the central level, i.e., the Ministry of Public Health, are not playing their role effectively in enabling full implementation of PBF best practices and theories.

In the mid-nineteenth century, with the influx of European immigrants into the cities, public schools became the answer to the poverty and ignorance of the urban masses. Then, in the late nineteenth century and early twentieth century, urban public schools were again called on to educate the many African-Americans who migrated to the cities from poor Southern states. Again, the idea of mass education of the public, funded by the public, became the panacea for all the problems of city living. The civil rights movement brought a flood of litigation, and courts attempted to provide equal educational opportunities to all students, even those in poor urban localities. Currently, urban public schools face the flight of middle-income families from the cities to the suburbs, within-district flight of more affluent families to private and parochial schools, and diminishing funds with which they must serve their populations. This study explored the factors that would influence middle-income families to return or remain in urban public schools to restore the original concept of a public education for all by all (Hunter & Donahoo, 2003) / Ed. D.

Smoking cessation can reduce health risk and prevent millions of tobacco-related deaths. However, cessation rates are low in low-and-middle income countries (LMICs), with only a small proportion of smokers intending to quit. Given the paucity of literature to support tobacco cessation programs in LMICs, this study aimed to: 1) identify factors associated with intention to quit smoking, 2) assess the relationship between health care provider quit advice/tobacco screening and utilization of cessation assistance, and 3) examine the relationship between home smoking rule and smoking intensity across three stages of smoking cessation (precontemplation, contemplation and preparation) in LMICs. Data were obtained from the Global Adult Tobacco Survey, 2009-2012, a nationally representative household survey of noninstitutionalized civilians aged 15 years and older. Weighted multivariable regression analyses were conducted using SAS version 9.4. Adjusted odds ratios (OR), percent change in smoking intensity and associated 95% confidence intervals (CI) were estimated. Home smoking rule and exposure to anti-smoking messages were the important factors associated with contemplation and preparation to quit smoking. Approximately 1%, 7%, 9% and 15% used quitline, medical treatment, counseling/cessation clinic and cessation assistance (all three combined), respectively, in the past year. Quit advice was significantly associated with utilization of counseling/cessation clinic (OR=3.89, 95% CI=2.8–5.5), medical treatment (OR=1.71, 95% CI=1.2–2.4) and cessation assistance (OR=2.60, 95% CI=2.0–3.4). Tobacco screening was associated with utilization of counseling/cessation clinic (OR=2.60, 95% CI=1.1–5.9) and medical treatment (OR=1.71, 95% CI=1.2–2.4). Living in a completely smoke-free home was associated with a 22.5% (95% CI=17.1%–28.0%), an 18.6% (95% CI=9.0%–28.2%), and a 19.4% (95% CI=3.9%–34.9%) significant reduction in smoking intensity among smokers in precontemplation, contemplation and preparation, respectively. In conclusion, the results suggest that smoke-free home, anti-smoking campaigns, and health care provider intervention promote smoking cessation in LMICs. Therefore, comprehensive smoke-free policies, anti-smoking media campaigns and integration of tobacco screening and quit advice into the health care system are important for tobacco cessation in LMICs, suggesting the need for full implementation of the World Health Organization Framework Convention for Tobacco Control Articles 8 and 11 – 13.

Increasing rates of adult-onset diabetes in low- to middle-income countries (LMICs) present a growing healthcare concern that requires a regulatory approach and local community engagement. Cross-sector collaboration (CSC) is an effective strategy for improving community health. CSC is not effectively used to manage adult-onset diabetes in LMICs, nor is there public policy advocating CSC in the management of diabetes. This qualitative exploratory case study explored how leadership and resources affect the use of CSC to assist in managing the adult-onset of diabetes in a CSC in Cameroon. A purposeful sampling strategy was used to identify participants for semistructured interviews of 10 executives involved in the CSC. CSC theory provided a theoretical framework. Collected data were organized by audio recording, transcribing, translating, member checking, and thematically coding data using NVivo 12 software. Data from a review of documents and researcher observations were triangulated with interview data. Findings revealed that poverty, access to health care, and rising diabetes prevalence contributed to environmental turbulence. Goal-setting and objectives, intersectoral-communication, fostering trust and respect, and sharing data and motivating people presented leadership effectiveness challenges. The following resource challenges emerged in the CSC: public policy, money, skills and expertise, equipment and supplies, and connection to the target population. This increased scientific understanding could help government policy-makers and nongovernmental organizations expand public policy leading to a decrease in the prevalence and burden of adult-onset diabetes.

INTRODUCTION: Epidemiological transition theory, first postulated by Omran in 1971, provides a useful framework for understanding cause-specific mortality changes and may contribute usefully to predictions about cause-specific mortality. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners due to lack of evidence from low- and middle-income countries. Therefore, understanding of the concept and development of epidemiological transition theory as well as population burden of premature mortality attributable to risk factors is needed. OBJECTIVES: This thesis aims to understand how epidemiological transition theory has been applied in different contexts, using available evidence on mortality transitions from high, middle- and low- income countries, as well as the contribution of risk factors to mortality transitions, particularly for premature mortality. METHODS: A Medline literature search from 1971 to 2013 was conducted to synthesise published evidence on mortality transition (paper I). A descriptive analysis of trends in cause of death using INDEPTH data was conducted, focusing on specific causes of death in 12 INDEPTH sites in Africa and Asia, using the INDEPTH 2013 standard population structure for appropriate comparisons across sites (paper II). A retrospective dynamic cohort database was constructed from Swedish population registers for the age range 30-69 years during 1991-2006, to measure reductions in premature non-communicable disease mortality using a life table method (paper III). Prospective cohort data from Västerbotten Intervention Programme from 1990 to 2006 were used to measure the magnitude of premature non-communicable disease mortality reductions associated with risk factor changes for each period of time (paper IV). FINDINGS: There were changes in emphasis in research on epidemiological transition over the four decades from 1971 to 2013, from cause of death to wide-ranging aspects of the determinants of mortality with increasing research interests in low-and middle-income countries, with some unconsidered aspects of social determinants contributing to deviations from classic theoretical pathways. Mortality rates declined in most sites, with the annual reductions in premature adult mortality varied across INDEPTH sites, Sweden, which now is at late stage of epidemiological transition stage, achieved a 25% reduction in premature mortality during 1991-2006. Overall downward trends in risk factors have helped to reduce premature mortality in the population of Västerbotten County, but some benefits were offset by other increasing risks. The largest mortality changes accrued from reductions in smoking, hypertension and hypercholesterolaemia. CONCLUSIONS: This thesis established patterns of current epidemiological transition in high, middle-and low-income countries (Asia and Africa), where the theory fits the transition patterns in some countries, but with some needs for further adjustments in other settings, as well as deviations from the classical ET theory in the last four decades. It highlights the need to identify the burden of mortality and morbidity, particularly for reducing mortality occurring before the age of 70 years and its attribution to risk factors, which are a major public health challenge. This informs shifting of public health priorities and resources towards prevention and control of chronic non-communicable disease risk factors.

Background: Children with disabilities living in low and middle income countries’ perceptions of participation are not shown in research. These perceptions are important for providing appropriate interventions. Aim: To describe how children aged 8-12 with an intellectual disability living in Ethiopia perceive their situation regarding participation in activities in everyday life. Method: A descriptive design with a quantitative approach was used. The sample was gathered using consecutive sampling. Fifteen structured interviews were conducted, using “Picture my participation,” an instrument under development. Analyses were made using SPSS Statistics and Microsoft Excel. Results: The children perceived that they participated in activities in everyday life. There was a broad variation in the activities the children prioritized as most important. On a group level, they were very involved in these activities. The majority did not experience any barriers to perform these activities. Conclusions: The perceptions of the majority of the children were that they were involved in daily activities. They did not experience any barriers to participation. The results should be read with caution and generalization is not possible, due to the sample characteristics and that the instrument is under development. / Bakgrund: Barn med funktionsnedsättningar som bor i låg- och medelinkomstländers uppfattningar om delaktighet är inte påvisade i forskning. Dessa uppfattningar är viktiga för att tillhandahålla lämpliga interventioner. Syfte: Att beskriva hur barn i åldrarna 8-12 år med en intellektuell funktionsnedsättning som bor i Etiopien uppfattar sin situation gällande delaktighet i vardagliga aktiviteter. Metod: En deskriptiv design med kvantitativ ansats har använts. Urvalet har samlats in genom konsekutivt urval. Femton strukturerade intervjuer genomfördes med användning av ”Picture my participation”, ett datainsamlingsinstrument under utveckling. Dataanalysen gjordes i SPSS Statistics och Microsoft Excel. Resultat: Barnen uppfattade att de deltog i vardagliga aktiviteter. Det var en stor variation i vilka aktiviteter barnen prioriterade som viktigast och på gruppnivå var de mycket delaktiga i dessa aktiviteter. Majoriteten av barnen uppgav att de inte upplevde några hinder för att utföra dessa aktiviteter. Slutsatser: Majoriteten av barnens uppfattning var att de är delaktiga i dagliga aktiviteter i hög grad och att de inte upplever några hinder för att delta. Resultatet bör tolkas med försiktighet och det är inte möjligt att generalisera resultatet, eftersom urvalet är litet och instrumentet är under utveckling.

The failure to translate evidence into clinical practice has been repeatedly highlighted. This failure is partly attributed to disregarding the context within which healthcare is delivered. The aim of this thesis was to develop and psychometrically evaluate the Context Assessment for Community Health (COACH) tool, and, through that process, provide opportunities to measure aspects of context perceived to be important for Knowledge Translation (KT) interventions in low- and middle-income countries (LMIC). All four studies in this thesis were mainly undertaken in Quang Ninh province, Vietnam during 2008–2014. Study II, however, was also conducted in four other LMICs (Bangladesh, Nicaragua, South Africa, and Uganda). Study I employed inductive content analysis of 16 focus group discussions to explore the influence of context in a community-based facilitation intervention in Vietnam. Studies II and III reported on the development of the COACH tool and assessment of its psychometric properties. Study IV used the COACH tool in a survey among health workers in Vietnam. To date, three sources of evidence regarding validity of the COACH tool have been provided, that is, test content, response processes, and internal instrument structure, with promising psychometric characteristics. The COACH tool could be used as means of characterizing aspects of context ahead of KT interventions, for tailoring KT strategies, and for further understanding of the results of KT interventions. / Context Assessment for Community Health

Within a panel data context with fixed effects method, using data on a sample of 40 lower- middle income economies, this paper investigates whether and to what extent FDI stimulates economic growth over the period 2007-2017. The main finding of this paper highlights the complementary effects between FDI and education, suggesting that a certain level of education must be reached in order for FDI to contribute positively on economic growth. Further, the level of education in this sample set is below the level that is considered as adequate in order to spur economic growth and thus this affects the absorptive capacity. This paper can only confirm that there is a certain association between FDI and economic growth and cannot confirm the widespread belief that FDI stimulates economic growth due to that the estimated models more often than not provided insignificant results.

This thesis studies the determinants and outcomes of the skill systems in Mexico and Turkey, two crucial cases of middle-income countries (MICs). Despite the similarities in their previous institutional environments and links to the global economy, Turkey has experienced higher economic growth and better social development compared to Mexico. This PhD project focuses on the Mexican and Turkish skill systems, which have been significant institutions that affect the (different) economic and social characteristics of advanced industrialised countries in the literature on comparative capitalisms (CCs). This study builds its theoretical approach on the arguments of CCs literature and the claims of globalisation, where it draws from the studies on global value chains (GVCs). It scrutinises the patterns of convergence due to globalisation and ongoing divergence because of the variation of institutional structures. It examines the complementarities and outcomes of the skill systems, which will then help to understand the divergence of development experiences between Mexico and Turkey. This PhD project carries out a multi-level research and focuses the empirical study on auto parts-automotive value chains (AACs), which is an important industry for many MICs including Mexico and Turkey. The multi-level research first includes a macro-level study of local institutions in Mexico and Turkey, as well as the convergence patterns through the AACs. This is complemented with a micro-level analysis of firms' strategies to find workers with technical skills in production functions. The findings show that while there is some convergence in the Mexican and Turkish auto parts producers' skill needs, firms from these two countries adopt different strategies to address their needs. The distinctive national institutions in Mexico and Turkey, which are shaped by the differences in the state's involvement, are the main reasons for this divergence. The differences between the Mexican and Turkish skill systems have created different outcomes for both the firms and workers in these countries, and hence are expected to have contributed to their diverging development paths.

INTRODUÇÃO: Países de baixa e média renda representam mais de 85% da população mundial de 7 bilhões de pessoas. Nesses países, a população idosa apresentou acelerado crescimento nas últimas décadas. Esse rápido crescimento está sendo acompanhado pelo aumento dos agravos relacionados ao envelhecimento e por mudanças no padrão de morbimortalidade. Entre as condições que têm demonstrado associação com aumento de mortalidade, está a depressão. Porém, grande parte das pesquisas sobre a associação da depressão com mortalidade é de países de alta renda. OBJETIVOS: 1) Investigar a associação entre depressão e mortalidade em idosos de países de baixa e média renda. 2) Investigar a associação de depressão/sintomas depressivos e mortalidade por todas as causas e causas específicas em uma coorte de idosos residentes na zona oeste de São Paulo em um período de 10 anos de seguimento. MÉTODOS: 1) Foi realizada uma revisão sistemática para identificar estudos observacionais que investigaram a associação entre mortalidade e depressão em países de renda média ou baixa. Dois revisores trabalharam independentemente para selecionar artigos, extrair dados e avaliar a qualidade dos estudos. Uma meta-análise foi realizada a partir dos dados extraídos dos estudos incluídos na revisão sistemática. 2) Foi realizado um estudo de coorte utilizando a amostra do \"São Paulo Ageing & Health Study\" (SPAH), investigação que incluiu idosos com 65 anos ou mais, residentes de áreas economicamente menos favorecidas na região Oeste da cidade de São Paulo. Os participantes foram identificados por arrolamento domiciliar e entrevistados em seus domicílios seguindo protocolo padronizado de pesquisa. A definição de depressão e sintomas depressivos foi realizada a partir dos instrumentos Geriatric Mental State (GMS) e Inventário Neuropsiquiátrico (NPI). Os dados de seguimento foram extraídos a partir das declarações de óbitos dos residentes do estado de São Paulo através de procedimento de linkage de dados com os bancos de declarações de óbitos da fundação SEADE. Foram examinadas as associações independentes entre depressão e sintomas depressivos e mortalidade através de modelos de riscos proporcionais de Cox e também foi elaborada curva de sobrevida de Kaplan Meier. RESULTADOS: 1) Foram incluídos 10 estudos, com um total de 13.828 participantes (2.402 deprimidos e 11.426 não-deprimidos) de 6 países (Brasil, 4 artigos; China, 2 artigos; Botswana, Índia, África do Sul e Coréia do Sul, 1 artigo). O risco relativo total não ajustado (RR) de mortalidade em idosos com depressão em relação aos não deprimidos foi de 1,62 (IC95% 1,39-1,88; p < 0,001), com alta heterogeneidade (I2, 66%; IC95% 33-83; p < 0,005). Após o ajuste para o viés de publicação, o RR geral diminuiu para 1,60 (IC95%; 1,37-1,86). Não foram observadas diferenças significativas entre os subgrupos, exceto aqueles definidos pela qualidade do estudo. Os estudos de alta qualidade tiveram um RR agrupado de 1,48 (IC95% 1,32-1,67), enquanto os estudos de baixa qualidade resultaram em um RR agrupado de 1,82 (IC95% 1,25-2,65). 2) Dos 1.967 participantes do SPAH, 443 (22,52%) apresentaram sintomas depressivos e 90 (4,58%) preenchiam critérios para diagnóstico de depressão pela CID-10 no início do seguimento. Foram observados 688 (34,98%) óbitos no seguimento. Presença de sintomas depressivos (HR=1,23; IC95% 1,03-1,46; p=0,022) e depressão (HR=1,75; IC 95% 1,29-2,37; p < 0,001) no início do seguimento estiveram positivamente associadas à mortalidade por todas as causas. Sintomas depressivos (HR=1,26; IC 95% 1,04-1,53; p=0,018) persistiram associados a mortalidade mesmo após controle por variáveis confundidoras, enquanto depressão (HR=1,20; IC95% 0,85-1,67; p=0,296) perdeu significância estatística ao se adicionar ao modelo variáveis relacionadas a comorbidades. Considerando causas especificas de óbitos, sintomas depressivos apresentaram associação significativa com óbitos por doenças cardiovasculares (HR=1,48; IC95% 1,12-1,95; p=0,006) e depressão apresentou associação com óbitos por câncer (HR=2,26; IC95% 1,17-4,36; p=0,015). CONCLUSÃO: A depressão está associada ao excesso de mortalidade em idosos que vivem em países de baixa e média renda. Além disso, esse excesso de mortalidade não difere substancialmente do encontrado em países de alta renda. Já sintomas depressivos e depressão estiveram associados ao aumento de mortalidade em idosos entre os participantes do SPAH. Dado que sintomas depressivos e depressão aumentam o risco de óbito, um melhor entendimento sobre essa relação e estratégias de provisão de serviços de saúde mental, em especial em países de média e baixa renda, são necessários já que essas condições clínicas modificáveis muitas vezes não são reconhecidas ou tratadas adequadamente / INTRODUCTION: Low and middle income countries represent more than 85% of the world population of 7 billion people. In these countries, the elderly population has grown rapidly in recent decades. This rapid growth is being accompanied by the increase in aggravations related to aging and changes in the morbidity and mortality pattern. Among the risk factors that have been shown to be associated with excess mortality are depression. However, much of the research on the association of depression with mortality is from high-income countries. OBJECTIVES: 1) To investigate the association between depression and mortality in the elderly living in low- and middle-income countries 2) To investigate the association of depressive / depressive symptoms and all-cause and specific-cause mortality in a cohort of elderly living in the western zone of São Paulo over a period of 10 years of follow-up. METHODS: 1) A systematic review was conducted to identify observational studies that investigated the association between mortality and depression in middle- and low-income countries. Two reviewers independently worked to select articles, extract data, and evaluate the quality of the studies. A meta-analysis was performed from the data extracted from the studies included in the systematic review. 2) A cohort study was carried out using a sample from the São Paulo Aging and Health Study (SPAH), an investigation that included elderly people aged 65 years and over, from economically disadvantaged areas in the western region of the city of São Paulo. Participants were identified by household survey and interviewed in their homes following a standardized research protocol. The definition of depression and depressive symptoms was performed using the Geriatric Mental State (GMS) and Neuropsychiatric Inventory (NPI) instruments. The follow-up data were extracted from the statements of deaths of the residents of the state of São Paulo through a data linkage procedure with the database of death declarations of the SEADE foundation. We examined the independent associations between depression and depressive symptoms and mortality through Cox proportional hazards models and also elaborated the Kaplan Meier survival curve. RESULTS: 1) Ten studies were included, with a total of 13,828 participants (2,402 depressed and 11,426 non-depressed) from 6 countries (Brazil, 4 articles; China, 2 articles; Botswana, India, South Africa and South Korea, 1 article) were included. The overall unadjusted relative risk (RR) of mortality in depressed relative to non-depressed participants was 1.62 (95% CI 1.39-1.88; p < 0.001), with high heterogeneity (I2=66%; 95% CI 33-83; p < 0.005). After adjustment for publication bias, the RR decreased to 1.60 (95% CI 1.37-1.86; p < 0.001). No significant differences were observed between subgroups except those defined by study quality. The high quality studies had a pooled RR of 1.48 (95% CI 1.32-1.67; p<0.001), while the low quality studies resulted had a pooled RR of 1.82 (95% CI 1.25-2.65; p < 0.005). 2) Of the 1,967 participants, 443 (22.52%) had depressive symptoms and 90 (4.58%) had a diagnosis of depression by ICD-10 at the beginning of follow-up. There were 688 (34.98%) deaths at follow-up. Presence of depressive symptoms (HR=1.23; 95% CI 1.03-1.46; p=0.022) and depression (HR=1.75; 95% CI 1.29-2.37; p < 0.001) at the beginning of follow-up were positively associated with all-cause mortality. Depressive symptoms (HR=1.26; 95% CI 1.04-1.53; p=0.018) persisted associated with mortality even after controlling for confounding variables, while depression (HR=1.20; 95% CI 0.85-1.67; p=0.296) lost association when variables related to comorbidities were added to the model. Considering specific causes of death, depressive symptoms had a significant association with death due to cardiovascular diseases (HR=1.48; 95% CI 1.12-1.95; p=0.006), and depression was associated with cancer deaths (HR=2.26; 95% CI 1.17-4.36; p=0.015). CONCLUSION: Depression is associated with excess mortality in the elderly living in low- and middle-income countries. In addition, this excess mortality does not differ substantially from that found in high-income countries. Depressive symptoms and depression were associated with increased mortality in the elderly. Given that depressive symptoms and depression increase the risk of death, a better understanding of this relationship and strategies for providing mental health services, especially in middle- and low-income countries, are necessary since these modifiable clinical conditions are often not recognized or properly handled