Introduction:
Pakistan has high prevalence of childhood malnutrition amongst developing countries. National Nutritional Survey 2018 showed 44% of children were stunted. Different circumstances have the potential to create inequality of opportunity in child health. This study aims to identify the drivers of inequality of opportunity in childhood malnutrition among children below five years of age in Pakistan.

Methods:
This study used Pakistan Demographic and Health Survey, 2017-18 to identify the role played by various factors in inequality of opportunity in child malnutrition. Dissimilarity index (D-index) and Oaxaca decomposition of D-index, and Shapely decomposition were used to measure and decompose inequality in opportunity in stunting. Regional variation in child health under various circumstances was analyzed using GIS.

Results:
The burden of stunting is exceptionally high in Pakistan. Prevalence of stunting in rural areas far exceeded the urban areas through 1990-2018. Shapely decomposition of the contributors of inequality in opportunity indicates that maternal education contributed to 24 % of total inequality for rural and 44% for the urban children. Water and sanitation contributed 22% to overall inequality in the rural and only 2% in urban areas, implying a critical part played by the lack of water and sanitation in rural areas. Wealth index predominantly contributed to inequality nationally and in the urban region. Southern regions have a high higher prevalence of stunting and higher proportion of households without adequate water and sanitation. Proportion of mothers without education and stunted children are largely concentrated in Baluchistan and Sindh.

Conclusions:
Lack of mothers’ education, inadequate access to water and sanitation services, and poverty are contributing factors to inequality of opportunity in stunting among under-five children in Pakistan. Understanding the critical part played by various circumstances would help policy makers to address the situation and take concrete steps to enhance equal opportunities for child health.