Community organizations working with local NGOs have been responsible for many of the most cost-effective initiatives to improve and extend provision for water and sanitation to low-income urban households. This has a growing relevance within an urbanizing world, with a large and increasing proportion of those with low incomes who lack provision living in urban areas. Along with considerable bearing on meeting the water and sanitation target within the Millennium Development Goals. This publication defines the scale of need before focusing on the role local, community-driven schemes provide in addressing the requirements of the unserved or ill-served in urban areas. Schemes that improved and extended provision for water and sanitation as a result of changes in approach by local governments and civil society organizations are detailed. This includes local initiatives not normally considered part of ‘water and sanitation’ which have been significant in improving and extending provision, especially squatter upgrading schemes, initiatives to provide land for new housing and measures to increase the availability of loans to support household and community investments in better housing. Often underpinning these successes were the partnerships offered to local government by organizations of the urban poor. The tools and methods used are examined along with the ‘local’ constraints to improving and extending provision for water and sanitation and how these can be successfully addressed.