Bridging the nutrition divide: understanding poverty-linked inequalities in under-five children health in Pakistan

Introduction Despite progress in reducing stunting and underweight among children in Pakistan, significant disparities remain between poor and non-poor households. Specifically, socio-economic inequalities, limited access to healthcare, and inadequate maternal and child nutrition primarily drive these disparities. Analyzing differences in child nutritional outcomes is crucial for understanding the underlying factors contributing to health inequalities, particularly across socio-economic strata. Nevertheless, there is not enough of empirical research that specifically investigates the determinants of these disparities in Pakistan by deconstructing child nutritional inequality in the country. This study aims to address this gap by identifying the key factors contributing to unequal child nutrition outcomes. Methodology This study examines data from the Pakistan Demographic and Health Surveys (PDHS) of 2013 and 2018, including 3,051 children from the 2013 PDHS and 4,013 from the 2018 PDHS. Height-for-age Z scores (HAZ) and weight-for-age Z scores (WAZ) are the outcome variables, alongside stunting and underweight as alternative outcome variables. Specifically Semi-parametric Method, Logistic Regression Model (LRM), and Blinder-Oaxaca decomposition are employed to investigate nutritional disparities and their fundamental drivers. The semi-parametric method identifies non-linear correlations frequently overlooked in conventional regression analysis. Results Children from non-poor households showed significantly higher HAZ scores by 0.75 standard deviations (SDs) and WAZ scores by 0.50 SDs compared to those from poor households. Major socioeconomic factors, including maternal education, access to healthcare, sanitation, and water facilities, mainly explain this difference. Blinder–Oaxaca decomposition analysis further clarified these inequalities, indicating that 62% of the HAZ gap and 54% of the WAZ gap stem from endowment effects. The prevalence of endowment effects indicates that structural inequities, rather than behavioral differences, are the principal obstacles to attaining SDG 2.2. Discussion This study highlights the importance of equity-focused policies to reduce child undernutrition in Pakistan by targeting key determinants such as maternal education, healthcare access, and systemic inequalities. Findings link better nutrition to improved cognitive and mental health outcomes, supporting inclusive social policies and SDG targets. Structural factors, rather than individual behaviors, primarily drive observed disparities and intergenerational health issues. Future research should explore targeted interventions addressing maternal education and service delivery inequities to achieve sustainable reductions in child undernutrition.