Rounding out the last 2 weeks’ exploration of countries based on the timing of their population peaks is Pakistan. It’s squarely in the UN World Population Prospects’ Group 3, i.e. countries whose population is likely to continue growing through 2054, reaching a peak later in the century or beyond 2100. It is joined in that group by some of the world’s most populous countries today, such as India, Indonesia, Nigeria, and the United States.
Fun fact: Pakistan is poised to rise from the 5th most populous country in the world currently to the third in 2054 (to India’s #1 and China’s #2 rank), remaining in place through 2100. See the moving and shaking in the top 10 below.
Source: UN World Population Prospects (2024)
I find the yellow arrows most interesting, which leads me to another fun fact: According to the UN, more than one-fifth of the projected increase in the global population between 2024 and 2054 is expected to be concentrated in nine countries: Angola, the Central African Republic, Chad, the Democratic Republic of Congo, Mali, Mayotte, Niger, Somalia and the United Republic of Tanzania (all likely to at least double in size in that time frame)! Due to this rapid growth, the ranking of the most populous countries in the world will likely change, with Pakistan and eventually Nigeria and the Democratic Republic of the Congo overtaking the United States of America in terms of population size by 2100.
Pakistan may be the most populous non-African Group 3 country at century-end and the last country of its income level and regional location to have not completed its demographic transition. Its demographic future was supposed to look like Iran’s. But it doesn’t. The reasons (as always) are complex, some of which I dig into today.
The Lady Health Worker Program
I mentioned Iran. It’s because the more I researched, the more parallels I began to draw with initiatives in both countries that had similar motives, but very different outcomes. Take for instance the fantastic Lady Health Worker (LHW) program (launched in 1994), which has echoes of Iran’s behvarz model (discussed last week). It is composed essentially of women from a community (serving their own community, so with in-built trust), with some basic schooling and training. Each LHW is responsible for a catchment of about 1,000 people in her community, with about 60% of the total country’s population accounted for at the peak of the program (and about 100K frontline workers). The LHW conducts home visits, delivers maternal and child health services, provides family planning counselling (including providing condoms and pills), routine immunization support, and health education. While not perfect, the program did show a range of positive outcomes: from increased antenatal care for pregnant women, increased contraceptive use among rural women, and improved development outcomes for children (like cognitive, motor, and language development).
Starting around 2010, things began to change. For one, a new constitutional amendment devolved health from the federal level to provinces. This resulted in each province taking control of their LHW program, and setting their own pay scales and priorities. It led to disparities that stung and led to protests and sit-ins that continue as recently as last year. For instance, LHWs in Sindh were paid almost double what LHWs in Punjab did for the same job. Additionally, LHWs were converted from contractors to civil servants (permanent government employees) in 2013 which created significant long-term financial obligations. This made the government hesitant to hire new workers, which should be regarded as a public health emergency. The population is expected to grow by about 1.5% per year, requiring a commensurate increase in critical aspects like LHWs. Indeed, if anything, the LHW program needed to be scaled up to account for the growing numbers of households in catchment areas.
A slight digression, because I love them. The LHW cadre is essential for (so much, but especially) immunization campaigns, since they are the only workers that women in conservative households will receive. I cannot emphasize enough how much that matters. This is why, when the CIA used a fake polio vaccination scheme to gain access to a compound where Osama Bin Laden and his family were suspected to be hiding, it created a massive setback to the trust placed in these community health workers. LHWs were accused of being spies, and 8 polio vaccination workers were assassinated, resulting in the suspension of UN polio eradication efforts in the country. It is currently only 1 of 2 countries in the world where polio is still endemic.
Overall Health System
Now it would be unfair to place the health of the entire Pakistani population on the shoulders of LHWs of course. While they form the lynchpin of the healthcare delivery system, the overall health system is severely underfunded. The country’s last Economic Survey (2024-25) shows that the total allocation for health accounts for less than 1% of the country’s GDP, despite growing population needs. There is only 1 doctor available for every 750,000 people (!) and there are currently only about 1,700 hospitals and 5,500 Basic Health Units operating across the country. To put that in context, consider that Pakistan’s population is about 240 million. The math should suggest a far greater investment in health as a matter of national urgency.
This of course translates into health outcomes. Neonatal mortality (infant death in the first 28 days of life) is one of the highest in the world (37.6 per 1000) while the maternal mortality rate (MMR) is 186 per 100,000 (improving, but still high).
Source: WHO (2025)
In fact, at the current pace of improvement for maternal deaths, UNFPA Pakistan reports that the country will end preventable deaths after (a whopping) 122 years (emphasis on the preventable!)
Source: UNFPA Pakistan (2024)
The Fertility Stall
Are you thinking, “Apoorva, you still haven’t talked about fertility!” Are you OK? I’m here, worry not. I have a few favorite demographers (I mean, who doesn’t?), and two of them - John Bongaarts and Zeba Sathar - wrote a definitive joint piece a few years ago on Pakistan’s puzzlingly slow fertility decline. In it, they find that the Total Fertility Rate (TFR) has basically not changed since 2012 (roughly around 3.2.) Compared to neighboring countries - Bangladesh and India - who are at replacement fertility today with a high contraceptive use, Pakistan still has one of the highest fertility and lowest contraceptive prevalence levels in Asia.
The reasons are many: There is persistently high desired family size (still above 3 children), a stalling demand for contraception, persistent son preference, early marriage, and a weak family planning supply chain outside the LHW network. Unlike Iran’s ability to get the blessing of the religious establishment for family planning, Pakistan’s Council of Islamic Ideology ruled FP un-Islamic in 1984 and never issued a full reversal (although they are warming up to it as a form of birth spacing). There is also evidence of 2.2 million unsafe abortions annually which may indicate that there is a need/demand for family planning services that is going unmet. Scholars have quantified the economic cost of unintended pregnancies and the benefits of investing in family planning in the country, which seems to resonate with decision-makers. Irum and colleagues (2025) calculated that every dollar invested in FP in Pakistan yields approximately $23 in cost savings across health, education, and infrastructure. This cost-benefic analysis challenges the misconception that family planning programs strain the public budget - perhaps a welcome quantification given the paltry allocation I mentioned earlier.
Which brings me to political will, calculations, and a lack of accountability. The 7th National Finance Commission Award (in 2010) tied 82% of provincial revenue-sharing to population count.
Source: SDPI (2025)
So if I understand it correctly, it means that each province has a fiscal incentive to grow its population and a disincentive to reduce (or attend to) fertility. From that same article,
When a district hospital lacks doctors because provincial budgets are stretched thin, or when a school struggles with overcrowded classrooms, these are symptoms of a system that prioritises headcount over outcomes. A formula that links funding to population rather than performance encourages political claims rather than service improvements.
Consanguinity
You know I love me a hook. If in Iran it was the water crisis, and in China it was the marriage market, I feel like I have to do one here. And perhaps it’s consanguinity. AKA cousin marriage. A few of my (lovely, dear) Pakistani friends have joked how unusual it is that they are not married to their cousins, but I don’t think I understood the magnitude of that until I read this statistic: Pakistan’s rate of consanguinity (the proportion of couples who are blood relatives) is unparalleled globally, with nearly two-thirds of marriages involving cousins. While cousin marriage rates have declined alongside economic development in many parts of the world, Pakistan’s rates have stayed roughly the same for several decades.
Our findings identify three key factors that sustain high rates of cousin marriage in Pakistan: intensive kinship systems, slower economic development, and higher fertility rates. These factors combine to create a unique socio-economic environment in which the advantages of marrying within the family outweigh its drawbacks.
The study applies the framework of intensive versus extensive kinship networks. Intensive kinship systems, common in traditionally agrarian societies like rural Pakistan, favor reinforcing existing ties to ensure economic and social cooperation. Cousin marriages facilitate mutual support in agricultural and business, and allow families to consolidate wealth, maintain land ownership, and strengthen family alliances. In contrast, societies with extensive kinship networks prioritize building broader social connections, often through marriages outside the kin group. Extensive kinship systems are generally associated with economic development and modern market economies, where formal education becomes common, people often move for work or school, and social connections become key to market opportunities.
Source: Shenk et al. (2024)
The operating system is something called biradari (think of it as a patrilineal descent group which organizes inheritance, political allegiance and voting behavior, and access to credit. It also organizes marriage, which is directly tied to the discussion above. I could cite a few papers, but honestly, I found this TikTok to be an excellent summary of the system, do watch if you are curious. Dense kin networks reward high fertility with patronage, labor, and political weight. If biradari weakens, say through known drivers like female education, urbanization etc., the fertility rate will fall. If biradari holds, the fertility rate will continue stalling to keep a steady pool of cousins for marriage.
If the topic of consanguinity was enough to wake you up today, consider watta satta: the simultaneous exchange of a brother-sister pair between two families. This is where it gets interesting. Research has found that it may actually be a net positive for a few things. Hear me out, if you absolutely had to marry your cousin, I think you would prefer a watta satta arrangement?:
The likelihood of marital discord is lower in watta satta arrangements as compared to conventional marriages. This result emerges most strongly in the case of estrangement, the clearest and most publicly observable expression of marital discord. But we also find that watta satta significantly reduces the probability of domestic abuse and of major depressive episodes. Since freedom from abuse and depression is undoubtedly a benefit, watta satta is clearly in women’s interest, regardless of whether the institution is ultimately motivated by parents’ altruism toward their daughters or by their desire to maintain family honor.
Source: Jacoby & Mansuri (2007)
I was curious to see if consanguinity is just as high in the Pakistani diaspora. The Born in Bradford study finds that 60% of couples of Pakistani heritage were blood relatives, but if both parents were born in the UK, that dropped to 30%. That is likely to further decrease, as the younger generation believes that community cohesion (a main reason for such marriages) can be forged even despite falling consanguinity.
The health cost of consanguinity
You guessed it - a whole lot of genetic diseases. Consanguineous marriages play a significant role in transmitting congenital defects and recessive diseases across generations, increasing the risk of adverse outcomes for children. One of the main ones is β-thalassemia, with more than 10 million carriers in the country. Complications include hypothyroidism, diabetes, infertility (quite the irony), anemia, and more). Treatment is intensive, with regular blood transfusions and iron chelation therapy required. Over 5,000 children with β-TM are born annually in Pakistan, where the carrier rate varies between 5% and 7% across different regions, with an average rate of 5%. Alarmingly, the life expectancy for a child born with the condition is 10 years.
This is an area where much progress has been made for carrier screening, education, and premarital counseling (three cheers for public health!) In Cyprus, the cases have decreased by up to 90% after the implementation of government policies to screen for thalassemia before marriage. While nascent in Pakistan, there is something to cheer about. Just last month, the National Assembly passed a bill to make premarital thalassemia screening mandatory for couples and all their blood relatives. This information will flow to marriage registers:
The Nikkah registrar shall keep and maintain these reports for at least two years from the date marriage is solemnized; and if marriage is solemnised in contravention of law, the licence of such registrar shall be cancelled or whoever, other than the Nikkah registrar, solemnized such a marriage shall be fined Rs100,000. In case a healthcare facility fails to carry out the necessary screening, its facility shall be held negligent to perform its duty and shall be charged a penalty of Rs100,000. It shall be compulsory for the healthcare facility to provide detailed genetic counselling with information on the pattern of disease and trait transmission. If the healthcare facility does not provide written and oral counseling, it shall be deemed to have been negligent of their duty and shall be penalised.
The Gig & Digital Economy
The formal economy in Pakistan is not creating jobs at the rate that new entrants are arriving, and will continue to arrive. The image below shows a nice snapshot of the labor force participation (2024-25):
Source: Gallup (2026)
Pakistan is currently in the midst of a massive youth bulge, with approximately 65% of its population under age 30. A failure to integrate these young people into productive employment can lead to an unrealized dividend, unrest, and more. The most striking number to me from the recent labor data (from figure above) is that the labor force sees an increase of 3.5 million people per year! A profound skills mismatch exists: while the country produces hundreds of thousands of graduates annually, employers struggle to find workers with the technical or vocational skills required for the modern market. Informal employment remains dominant in Pakistan’s labor market, accounting for 81% of total employment. These large numbers of young people entering the labor market all need to work somewhere to earn a living.
Enter: the gig economy (is it Pakistan’s version of jugaad?) Contrary to what you may think of when you hear the term, Pakistan’s gig economy is no Silicon Valley story. According to Gallup, it’s a household resilience story that is filling gaps left by formal job creation. Unlike Silicon Valley, here, 97.1% of gig workers are engaged in physical platform-based activities while only 2.9% perform fully online digital work. There are estimated 2.5M freelancers in the country, and consistently rank among the top earners worldwide, particularly in software development, web design, and digital marketing
Source: Gallup (2026)
In structural terms, this means that Pakistan’s gig economy is anchored in urban transport, food delivery, rise of home chefs, and logistics systems. It represents digitized coordination of physical labor rather than the large-scale migration of workers into high-skill remote digital employment.
Gig Economy and Gender
The recent Labor Force Survey (LFS) conducted by the Pakistan Bureau of Statistics shows that for primary jobs, 2.9% of workers are engaged in gig-based work, while for secondary jobs, gig (short-term) work rises to 10.6%, with women playing a more prominent role — 15% of women with secondary jobs rely on gig work, compared to 9.8% of men. Concurrently, female entrepreneurship rose sharply from 19% in 2020-21 to 25%, while the share of contributing family workers — predominantly unpaid women — declined from 21% to 19%, reflecting greater female entry into paid labour.
Tantalizingly, the gig economy in Pakistan, particularly through platforms like Upwork and Fiverr, serves as a transformative tool for women’s empowerment by bypassing traditional barriers such as restricted physical mobility and patriarchal social norms. According to recent research, these digital platforms offer a bridge that allows women, especially in rural and peri-urban areas, to participate in the global labor market, leading to increased financial independence and a measurable shift in intra-household decision-making power. However, significant structural hurdles persist, including the digital divide, lack of legal protections, and cultural pressures where male family members may still exert control over women’s earnings. While government initiatives continue to promote freelancing to boost IT exports, true empowerment will require addressing these systemic inequalities and ensuring that digital inclusion translates into sustainable social and economic agency.
Who knows - maybe freelancing and platform work might replace biradari as the reputational network for young urban workers. This digital decoupling could also disrupt the growth trajectories of the very countries hiring these freelancers. While both Pakistan and the US are currently classified as Group 3 countries, that momentum in the West has long been fueled by migration. If labor becomes a borderless digital export rather than a physical one, what will that mean for migration, timing of population peaks, and more?
The Climate Crisis
A 2025 global assessment of recent extreme weather events sponsored by the German government found Pakistan more vulnerable to climate change than any other country. This is due to a perfect storm of geographic and climatic factors: it houses the largest concentration of glacial ice outside the polar regions (often called the Third Pole) while simultaneously being situated in a path of increasingly erratic and intense South Asian monsoons. As rising global temperatures accelerate the melting of its 7,000+ glaciers, the resulting runoff combines with extreme rainfall to overwhelm the Indus River system, leading to catastrophic cascading disasters like the 2022 floods that submerged a third of the country. This physical vulnerability is compounded by a stark climate injustice; despite contributing less than 1% of global greenhouse gas emissions, Pakistan remains one of the world’s most at-risk nations, facing a deadly cycle of record-breaking heatwaves and unprecedented inundation that its agrarian-dependent economy and fragile infrastructure are ill-equipped to withstand. Similar to Iran, Pakistan also faces water woes, further exacerbated by geopolitical tension with India in recent years.
Burning fossil fuels for transportation, heating fuel, waste incineration, electricity generation, and other industrial activities is responsible for increasing levels of air pollution. While all these seem to be natural by-products of growing populations and economic production, they are affecting more than just quality of life: air pollution in Pakistan shortens average life expectancy by 3.9 years. Of Pakistan’s cities, Lahore is the worst affected, with air pollution cutting life expectancy by seven years.
With freelancing and platform work largely indoor and laptop-based, perhaps the gig economy is also a climate adaptation strategy for a labor force that cannot physically be outside.
Conclusion
This week, I was in New York at the United Nations Commission on Population and Development. It’s held every year, and assesses progress on the implementation of the 1994 International Conference on Population and Development (ICPD) Programme of Action, focusing on population trends, sustainable development, and reproductive health. This year’s theme was Population, technology and research in the context of sustainable development, and it couldn’t have been better background music for this week’s Substack.
In a way, Pakistan’s current trajectory is a test case for the Commission’s central theme: that technology and research are not just accessories to development, but form the very infrastructure of survival. The discussions emphasized that while digital technologies offer an unprecedented chance to accelerate all 17 Sustainable Development Goals, they also risk deepening the digital divide if not anchored in human-centered policy. For a nation like Pakistan, where 3.5 million young people enter the labor force every year, the forward-looking concept of demographic resilience - capacity of societies to proactively anticipate, adapt to, and manage profound population changes- is the urgent requirement to turn a youth bulge from a looming crisis into a resilient dividend. If Pakistan can harness the Commission’s call for responsible innovation: for example, by using telemedicine to supercharge the LHW network or using AI to predict and plan for various climate crises, it can prove that demography is not destiny. Pakistan’s demographic future was supposed to look like Iran’s. The next 25 years will decide if it ever does — or if the country becomes the first Group 3 state to miss its transition entirely.
The Food!
We were deciding between nihari and haleem, and went with the former. Simply because time was limited, and my mom makes the best haleem so I wasn’t even going to attempt it. Our nihari turned out so well (shout out to Sam for his recipe)! We ate it with sheermal (a sweet bread), some naan, shammi kabab (frozen), and Ekim’s salad. Kimaya did her research and shook her booty to Pasoori. We were spoiled for choice musically-speaking: bounced between various Coke Studio Pakistan bangers and the GOAT Nusrat Fateh Ali Khan. If/when Eymir gets to his research, I am going to try to spark an interest in cricket. Someday, maybe by the time he is older, the Indo-Pak cricket tensions will ease and we will get back to enjoying the countries playing against one another with a real spirit of sportsmanship.
Fantastic read!