The Khorezm region is located in the northwest of Uzbekistan, approximately 350 km from the current shore of the Aral Sea. It comprises a large‐scale irrigation system that conveys water from the river Amu Darya to agricultural land cropped mainly with cotton, wheat, and rice. Khorezm's water resources are vulnerable as they depend on upstream developments and are indispensable to rural livelihoods and state budgets. Since water scarcity is expected to increase in the future, sustainable water management is a necessity. Hence, the objectives of the paper are to: (1) conceptualize the distinctive features of water management in Khorezm; (2) provide an integrated analysis of water management by establishing linkages between society, technical infrastructure, and the bio‐physical environment; and (3) make policy and technology recommendations for improved water management. To conceptualize water management in Khorezm, the paper distinguishes three types of practices: formal practices, strategic practices, and discursive practices. Based on these, it presents an analysis of water management on the state water management level, the water user association level, and the farmer and field level. For each level, recommendations are given. The paper concludes that elements of integrated water resources management (IWRM) such as transparency, accountability, participation, and technical efficiency are relevant to improve water management in Khorezm, as elsewhere. In addition, it underlines the need to create legal space for agency and innovation. Technical tools such as models are increasingly important for facilitating transparency and enabling agents to access and make use of information across the management hierarchy.