The complex interactions between human activities and the environment at the interface of land and water is analyzed with a focus on the Somali Current (East Africa), and Indian Ocean Island States, subregions of the Global International Waters Assessment (GIWA). These 2 subregions contain some of the world's richest ecosystems, including the high biodiversity forests of Madagascar and the diverse coastal habitats of the eastern African coast. These ecosystems support local communities and national and regional economies. Current and future degradation of these systems, from water basins to continental shelves, affects the livelihoods and sustainability of the countries in the region, and long-term efforts to reduce poverty. The assessments determined that pollution and climate change are the primary environmental and social concerns in the Islands of the Indian Ocean, while freshwater shortage and unsustainable exploitation of fisheries and other living resources are the primary environmental and social concerns in East Africa. The GIWA approach, through assessing root causes of environmental concerns, enables the development of policy approaches for mitigating environmental degradation. This paper explores policy frameworks for mitigating the impacts, and reducing the drivers, of 3 environmental concerns—freshwater shortage; solid waste pollution; and climate change—addressing social and institutional causes and effects, and linking the subregions to broad international frameworks. The common theme in all 3 case studies is the need to develop integrated ecosystem and international waters policies, and mechanisms to manage conflicting interests and to limit threats to natural processes.