The quality of surface water in many parts of the world, especially in developing nations is being challenged by rapid economic growth, demographics and climate change leading to widespread and severe degradation of fresh water ecosystems. With many rivers still in good condition, there are opportunities to prevent pollution and begin restoration. However, severe organic pollution is already affecting around one in seven rivers across Latin America, Africa and Asia. This poses a growing risk to public and environmental health, food security and the economy. Freshwater systems in both developed and developing nations are facing growing pressure from the discharge of harmful chemicals, such as hormone disrupters. Unfortunately, municipal water treatment has become increasingly costly and developing countries in particular have problems matching expanding public water supplies and sewerage, with inadequate treatment facilities for the newer/higher wastewater flows. As a result there is a significant risk to vital activities like inland fishing, which accounts for some 60 million jobs and almost a third of fish harvested for human consumption. Yet, until now, insufficient collection and evaluation of data has made it difficult to grasp the intensity and scope of deteriorating water quality. Sound knowledge is critical to understanding the underlying causes and developing the evidence based policies to improve it, including source control, waste treatment, ecosystem management and new forms of local and global governance. By providing a snapshot of the current situation, success stories and future challenges, this review offers a baseline to measure progress, a framework for global assessment and a pathway towards sustainable solutions for river water remediation and restoration which will assist countries looking to establish their own planning, monitoring and guidelines.