In 2005, an estimated 15.2 millionpeople or 80 percent of the total population of the AmharaRegion in Ethiopia lived in rural areas wheresanitation-related indicators were low. Open defecation wascommon; hand washing, particularly after defecation, waspracticed infrequently; and general housing environmentswere unsanitary, with cohabitation with animals a commonoccurrence. There was a high prevalence of health issuescorrelating to poor sanitation and hygiene such asintestinal parasites, diarrhea, and eye and skin diseases.During that timeframe, the Water and Sanitation Program(WSP) worked with the Ministry of Health, providing supportto design a Sanitation Strategy and On-Site Sanitationprotocol. WSP also gained experience in scaling upsanitation by working closely with the Southern Nations,Nationalities, and People's Regional Government HealthBureau. These experiences and government motivation tochange conditions provided an opportunity to design acommunity-led, systematic approach to implement asustainable at-scale sanitation program based on thestrategy and protocol.