Climate change and other challenges force cities to reconsider their governance structure. Are they ready to deal with the consequences of flooding, more rain or sea level rise? After presenting one approach to dealing with such urban issues in an integrated way, a classification of risks is presented, focusing in particular on what that means for Third World cities. Current governance structures are often not able to deal with these challenges, which require reform and appropriate decision making structures. Some proposals are made for such structures. The issue is illustrated for China and Ghana. In the latter case the strategic directions for integrated urban water management are developed in cooperation with a group of concerned local experts.