Irrigated agriculture in Pakistan provides food and livelihood security for about 220 million people, mostly living in Punjab and Sindh provinces. This review paper explains the institutional arrangements for water supply and on-farm water management along with their roles. Successful elements covering decades of efforts have also been studied. The implications of less profitability of the farming business are also identified. This paper articulates multiple investments for irrigation infrastructure expansion, on-farm water management, and promotion of resource conservation technologies including public sector demonstration and research projects, cost-sharing/subsidized schemes, and technology introduction with associated training and learning approaches. This draws a clear picture of present-day agriculture and has helped in identifying cracks in the implementation of these practices that need mending for more definitive outcomes. These efforts have resulted in considerable enhancements including, increasing water availability, cropped areas and cropping intensity, promotion of resource conservation technologies, and farm mechanization. Despite these attempts, farming is no more a profitable business for the majority of farmers while water productivity remains the lowest in the region. There is a constant decline of the share of agriculture sector and labor in gross domestic product of the country. The divide between on-farm water management and irrigation departments, requires formulation of a new governance model keeping in view the past experiences to make farming a profitable business.