Study region: Iran, as a representative arid region grappling with a severe water crisis in its agricultural sector. Study focus: This study aimed to conduct a pathology of Sustainable Water Governance (SWG) in the agricultural sector of Iran by systematically analyzing structural, contextual, and behavioral challenges. The research employed a deductive qualitative content analysis (QCA) approach, utilizing the DPSIR (Driving forces, Pressures, State, Impacts, Response) assessment model integrated with a three-pronged pathology model (structure, context, behavior). Data were gathered from 109 peer-reviewed articles (69 international, 40 Iranian) and 11 in-depth interviews with Iranian water governance experts. New hydrological insights for the region: Analysis of the literature and interviews yielded 284 indicators. Findings revealed the most significant driving forces to be weak policymaking, institutional fragmentation, and neglect of indigenous knowledge. Key pressures included population growth and inappropriate cropping patterns, which have resulted in declining groundwater resources, desiccation of rivers, and inefficient management structures (state). The crisis impacts have intensified social tensions, food insecurity, and migration. Effective response strategies for the region emphasize stakeholder participation, cropping pattern reform, policy transparency, and integrated water resources management (IWRM). By proposing a three-dimensional pathology (diagnostic) framework, this study provides regional policymakers with a strategic tool to enhance the agricultural sector's resilience in confronting the water crisis, with potential applicability to other arid regions facing similar governance challenges.