This paper provides a synopsis of environmental and health impacts arising from agricultural water development in sub-Saharan Africa and recommends ways to increase the sustainability of investments in irrigation by giving greater prominence to health and environmental concerns. In many places in the region, irrigation is a key means of enhancing agricultural productivity that can reduce poverty and improve livelihoods. However, failure to adequately foresee, plan and manage the negative environmental and health impacts arising from irrigation undermines the sustainability of many schemes and can worsen poverty. To improve sustainability, environmental and health issues must be at the core of future irrigation development with much greater emphasis on the planning and management of potentially negative impacts. This paper presents a conceptual framework for considering environmental and health issues in tandem; reviews current environmental and health assessment tools; describes national and donor policies; and analyzes current constraints to successful environmental and health planning and management. On the basis of findings, it makes recommendations to improve planning and management across a range of scales. The recommendations are of relevance to both water and agricultural planners and are timely, in the light of recent calls for significant increases in irrigation investment as a contribution to achieving the Millennium Development Goals.