Water in the Middle East and North Africa region already causes major social and economic problems, resulting from insufficient supply, unreliable services and environmental damage. Per capita availability will fall by half by 2050, water quality is deteriorating, many aquifers are on the verge of exhaustion, and climate change may alter rainfall patterns. Unless current practices change, then, the situation will worsen considerably. For years, water professionals have been advocating comprehensive water reforms. Yet, although most countries have made considerable progress improving water policies and institutions, some of the most important elements of reform have remained politically intractable. Now, a series of factors are emerging that represent a potential opportunity to break this impasse. Turning the potential into real improved water outcomes will depend upon three things. First, developing reform proposals that that respond to the dynamics of the political economy. Second, recognizing that the water sector cannot act alone. Some of the reforms that will have most impact on water outcomes relate to policies such as trade, agriculture, finance, energy, and social protection. Third, implementing policies and practices that increase accountability of government institutions and service providers to the public.