Much current work on climate adaptation options vis-à-vis water management in rural sub-Saharan Africa has tended to focus more on technological and infrastructural alternatives and less on institutional alternatives. Yet, vulnerability to climate variability and change in these contexts is a function not just of biophysical outcomes but also of institutional factors that can vary significantly at relatively finer scales. This paper seeks to contribute towards closing this gap by examining institutional options for sustainable water management in rural SSA in the context of climate change and variability. It explores challenges for transforming water-related institutions and puts forward institutional alternatives towards adapting to increasingly complex conditions created by climate change and variability. The paper suggests revisiting the Integrated Water Resources Management approach which has dominated water institutional debates and reforms in Africa over the recent past, towards actively adopting resilience and adaptive management lenses in crafting water institutional development initiatives.