Pakistan is adding five to six million people annually. The 2023 Census recorded 241.5 million people, an increase of 33.8 million in six years. The annual growth rate of 2.55% reversed a decades-long decline. At this pace, Pakistan could approach 400 million people by 2050.
Our predicament is particularly disturbing when compared with our peers. In the 1970s, Pakistan, Bangladesh, India, Indonesia and Iran faced broadly similar demographic challenges. Today, fertility rates have fallen to approximately 2.1 children per woman in Bangladesh, 2.0 in India, 2.1 in Indonesia and 1.7 in Iran. Pakistan remains at 3.6.
The consequences are everywhere. Approximately 20 million children aged five to sixteen are out of school. Public health expenditure is below 1% of GDP. Per capita water availability has fallen below the scarcity threshold of 1,000 cubic metres. The economy must create roughly 2.5 to 3 million jobs annually for new labour-market entrants. Housing, food supplies and urban infrastructure are under relentless pressure. Population growth is not the sole cause of these problems, but it magnifies every one of them. Even improvements in economic growth and public investment are diluted by rapid population growth.
Pakistan recognised the challenge early, launching a national family planning programme in 1965. Since then, successive governments have established ministries, departments, welfare centres, mobile units and national action plans. Billions of rupees, supplemented by international assistance, have been spent. Yet the results remain deeply disappointing.
The last consolidated national inventory recorded 3,439 Family Welfare Centres, 261 Reproductive Health-A Centres and 295 Mobile Service Units, supported by thousands of personnel. Maintaining this infrastructure consumes substantial resources, but has failed to produce sustained fertility reduction. Indeed, Pakistan's strongest progress came in the 1990s, when contraceptive prevalence doubled from approximately 12% to 24% in six years, supported by community-based Lady Health Workers, NGOs and dedicated financing. Those arrangements subsequently weakened.
In 2018, the Council of Common Interests committed Pakistan to reducing fertility to 2.8 by 2025 and 2.1 by 2030. The first deadline has passed; fertility remains around 3.6.
After six decades of expenditure, programmes and missed targets, Pakistan does not need another ministry or another army of government employees. It needs a small, competent institution that funds capable providers, measures results and enforces accountability.
The problem is not simply inadequate supplies. Women often avoid contraception because of side-effect concerns, family opposition, unreliable information and inadequate counselling. More government facilities cannot resolve these barriers. They require trusted women engaging regularly with households, explaining choices and providing follow-up. Bangladesh's well-documented Matlab experiments demonstrated that sustained household engagement achieves more durable results than simply making contraceptives available.
In 1998, the Prime Minister tasked me with researching Pakistan's population problem and proposing a solution. Working with Babar Hussain, I developed an alternative to government-operated delivery. Nearly three decades later, that solution (which got lost in the transfer of power following the Oct 12, 1999 coup) remains just as relevant. Pakistan's population was approximately 130 million then; it has almost doubled, yet we continue relying on an institutional model that has not delivered the required results.
Our proposal is straightforward: government should stop operating an expensive population welfare delivery bureaucracy and instead finance qualified NGOs, contracting them to achieve measurable results and holding them accountable for performance. An updated, detailed proposal is available at pakistanplan.org.
A lean, professional National Population Board, chaired by the Prime Minister and operating through the Prime Minister's Office, would accredit NGOs, manage a national population fund, award contracts, establish standards and independently monitor results. It would not operate welfare centres, employ field workers or create another provincial bureaucracy. A small team of public health, finance, procurement and monitoring professionals would suffice.
Accredited NGOs would compete for district contracts, recruiting and supervising women from local communities to provide household counselling, contraceptive access, follow-up and medical referrals.
The payment mechanism is crucial. NGOs would receive a limited mobilisation advance, but most payments would depend on independently verified results—not household visits, contraceptives distributed or initial enrolments. The principal measure should be sustained, voluntary contraceptive use over a defined period, such as twelve months, with the ultimate objective of reducing fertility and bringing population growth progressively towards sustainable levels.
Independent monitors would verify outcomes through records, household sampling and surveys. To ensure transparency, district- and provider-level results would be publicly reported. Successful NGOs would win further contracts; unsuccessful ones would lose funding.
Informed consent and method choice must be protected, with no payments to individual women or incentives for coercion.
Implementation would begin in selected districts and expand after evaluation. Existing facilities would close only once replacements were operational, with useful assets and personnel transferred to provincial health departments where appropriate.
Existing population welfare budgets could be redirected towards verified outcomes, supplemented where necessary by development partners.
Fiscal incentives must also change. Population currently carries an 82% weight in the National Finance Commission formula for distributing resources among provinces. Provinces receive no direct reward for reducing fertility. We propose including demographic performance as a criterion in the next NFC Award.
After six decades of expenditure, programmes and missed targets, Pakistan does not need another ministry or another army of government employees. It needs a small, competent institution that funds capable providers, measures results and enforces accountability. The state remains responsible for policy and outcomes; it need not deliver every service itself.
Almost three decades after Babar Hussain and I proposed this alternative, Pakistan has added more than 110 million people. We cannot afford another three decades of doing what has not worked. The objective must be simple: stop financing administrative activity and start purchasing results that reduce population growth.