When the Hygiene Improvement Project (HIP) began in 2004, nearly 80 percent of the total population of the Amhara Region in Ethiopia (an estimated 15.2 million people) lived in rural areas where access to sanitation was extremely low and hygiene behaviors were not widely practiced. The majority of the population, 64 percent, practiced open defecation, and just 17 percent of the population had access to only “unimproved” sanitation facilities such as pit latrines. Eight percent of households treated water prior to use, and just 21 percent reported using a cleansing agent such as soap during any one of the critical junctures of diarrheal disease, such as before cooking, before eating, after wiping a child’s bottom, or after defecating.
Due to the enormity of the challenges in this large region, an integrated and significant at-scale approach was needed. In order to reduce diarrheal disease and enable Ethiopia to meet the Millennium Development Goal for sanitation, USAID offered partners a new at-scale approach that not only focused on latrine building and hardware, but also on demand creation and the enabling environment throughout the region.