Urban wastewater is increasingly used for agricultural production, particularly in those areas where access to fresh water resources is limiting. Depending on the prevailing institutional arrangements, this agricultural use is planned or unplanned. If planned, a general policy is to minimise health risks and environmental pollution, leading to an often centralised collection of the city’s sewage, followed by primary, secondary and further treatment until the prevalent discharge effluent use standards are met. If society can afford them, advanced treatment technologies are installed, backed by a well functioning institutional infrastructure. In contrast, in less prosperous countries the agricultural use of wastewater is driven by the high needs for water and the absence of affordable fresh water resources along with insufficient financial means to construct treatment systems and distribution networks that comply with the official regulations. Combined with a poor institutional framework, this results in unplanned and unguided direct or indirect use of raw, partially treated or diluted wastewater. In an effort to mitigate health and environmental problems, we propose using a reverse water chain design approach, in which the ultimate fate of the water is the basis for the design of conveyance and treatment facilities.