Many people believe that simply providing a fresh, clean water supply will substantially reduce water-borne illnesses. What most people do not know is that safe hygiene practices and access to sanitation are crucial for combating the main health threats to children under five, in particular diarrhoea. Approximately 88 per cent of all diarrhoea infections worldwide are attributed to unsafe water supply, the lack of safe hygiene practices and basic sanitation infrastructure (Evans 2005). And the scale of the problem is immense: today, nearly twice as many people lack access to sanitation compared with water supply (UN 2005). In recent years, sanitation has risen up the international policy agenda. In 2002, sanitation was included in the Millennium Development Goals (MDGs), and specifically within MDG 7, Target 10, which sets the aim of halving ‘by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation’. Yet, at national level in most developing countries, hygiene and sanitation do not yet receive much attention, despite important health implications. The aim of this report is to explore the underlying reasons for this apparent paradox.