Water is a finite resource and should be given the attention it deserves to reduce its depletion through leakages in pipe systems. The authors implemented pressure management strategies linked to fixed and variable discharge (FAVAD), the burst and background estimate (BABE), and orifice principle methodologies to analyze a two-phased comparative method for applying optimal pressure management and its efficiency indexes in measuring volumetric cost performance, consumption, leakage flowrate, linear leakage reduction, infrastructural leakage and leakage cost indices. Using time-modulated smart control pressure reducing valve (PRV) simulation processes, the authors selected Alexandra Township in Johannesburg, South Africa as a case study. The results showed a reduction in head pressure, a reduction in the system input volume (SIV) from 26,272,579 m3 to 21,915,943 m3 and a reduction in minimum night flow (MNF) from 14.01% to 12.50%. The annual estimated nodal system output (NSO) was reduced from 14,774.62 m3 to 12,787.85 m3. The monthly average linear system repairs were reduced from 246 to 177, while the efficiency index percentages of leakage frequency/km/pressure were reduced from 8.31% to 5.98%. At a unit cost of $3.18/m3, the cost of leakages declined from $4,009,315.54 to $2,862,053.10 per month, while average household consumption (AMC) reduced from 36.33 m3 to 24.56 m3. Finally, the linear reduction value R2 for the percentage of the total leakage flowrate (TLFR)/SIV declined from 0.58 to 0.5, whereas the infrastructure leakage ratio (ILI) increased from 4 to 4.3. The results fully demonstrated that optimal pressure management is an alternative way to simulate, estimate, quantify and understand where and how water is lost in a distribution system. The authors propose that the implementation of proactive leakage management and domestic background leakage repair could further assist in reducing the frequency and cost of water leakages.