Since 2002, the SNNPR government, one of the 11 regional states of Ethiopia, trialled a new approach of broad based, low-cost, high-impact public health interventions aimed at improving basic health status of the region, including access to sanitation and hygiene (S&H) services. Four years since the initiation of the new approach, the Bureau of Health (BoH) reported a substantial growth in access to sanitation facilities in the region, from 16% in 2002 to 90% in 2006. The reported success gained wide attention considering S&H is given a low policy priority in many developing countries and because the region’s policy was home grown and without major donor support. RiPPLE conducted a case study on the SNNPR government’s S&H approach and implementation experience in order to identify promising scalable practices and use lessons from SNNPR as a basis for developing similar programmes with the rest of the country and the Nile region, more generally.The case study includes three components – a technical study; a ‘Knowledge, Attitude and Practice’ study, and; an analysis of the policy and institutional factors affecting the uptake and implementation of the approach – the latter one being the focus of this working paper.