Population centres in low atoll islands have water supply problems that are amongst the most critical in the world. Fresh groundwater, the major source of water in many atolls, is extremely vulnerable to natural processes and human activities. Storm surges and over-extractions cause seawater intrusion, while human settlements and agriculture can pollute shallow groundwaters. Limited land areas restrict freshwater quantities, particularly in frequent ENSO-related droughts. Demand for freshwater is increasing and availability is extremely limited. At the core of many groundwater management problems are the traditional water ownership rights inherent in land tenure and the conflict between the requirements of urbanised societies and the traditional values and rights of subsistence communities living on groundwater reserves. Resource limitations and geographic isolation restrict the potential for increasing wealth through crop exports. Water governance reforms and the provision of knowledge to communities are critical. Regional water organisations, fostering self-support, are a key to developing island-adopted and owned solutions.