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INTRODUCTION: Undernutrition affects ∼165 million children globally and contributes up to 45% of all child deaths. India has the highest proportion of global undernutrition-related morbidity and mortality. This protocol describes the planned economic evaluation of a community-based intervention to improve growth in children under 2 years of age in two rural districts of eastern India. The intervention is being evaluated through a cluster-randomised controlled trial (cRCT, the CARING trial). METHODS AND ANALYSIS: A cost-effectiveness and cost-utility analysis nested within a cRCT will be conducted from a societal perspective, measuring programme, provider, household and societal costs. Programme costs will be collected prospectively from project accounts using a standardised tool. These will be supplemented with time sheets and key informant interviews to inform the allocation of joint costs. Direct and indirect costs incurred by providers will be collected using key informant interviews and time use surveys. Direct and indirect household costs will be collected prospectively, using time use and consumption surveys. Incremental cost-effectiveness ratios (ICERs) will be calculated for the primary outcome measure, that is, cases of stunting prevented, and other outcomes such as cases of wasting prevented, cases of infant mortality averted, life years saved and disability-adjusted life years (DALYs) averted. Sensitivity analyses will be conducted to assess the robustness of results. ETHICS AND DISSEMINATION: There is a shortage of robust evidence regarding the cost-effectiveness of strategies to improve early child growth. As this economic evaluation is nested within a large scale, cRCT, it will contribute to understanding the fiscal space for investment in early child growth, and the relative (in)efficiency of prioritising resources to this intervention over others to prevent stunting in this and other comparable contexts. The protocol has all necessary ethical approvals and the findings will be disseminated within academia and the wider policy sphere. TRIAL REGISTRATION NUMBER: ISRCTN51505201; pre-results.

There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities.

Objective: This study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending. Methods: Data for this study were collected as a part of the situational analysis for the "Diagonal Interventions to Fast Forward Enhanced Reproductive Health" (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. Results: The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03-7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were "receiving [money] from partner or household members" (69 %) and "using own savings or regular income" (44 %), respectively. Conclusion: Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family -although this requires further study.