This review largely focuses on government/formal water management and governance systems in Khyber Pakhtunkhwa and Punjab provinces and outlines a number of key challenges that are common across the two provinces. Challenges can be grouped into three categories, i.e. challenges at the management and governance level, challenges related to financial stability and lack of investment and challenges related to mega-trends. This review draws on recommendation for improving formal water management and governance which includes improving monitoring and evaluation, capacity building, installing water meters, proper waste and wastewater management and regulation including building treatment plants, and raising awareness of water conservation (SBP, 2017; IUCN, 2014, p. 33). It also identifies that gender is extremely important in terms of both access to water and sanitation and participation in decision-making processes and governance (see for example, Nadeem et al., 2013).