In a rural district in Malawi, poorly motivated health personnel, shortages of human and financial resources, weak dialogue between existing tuberculosis (TB) and human immunodeficiency virus (HIV) programmes and poor community involvement are constraints to establishing joint TB-HIV interventions. The presence of a non-governmental organisation (NGO), Médecins Sans Frontières (MSF), in the health care delivery system provided an opportunity to bridge some of these gaps. The main inputs provided by MSF included additional staff, supplementary drugs including antiretroviral drugs, technical assistance and infrastructure development. The introduction of a scheme of monthly performance-linked incentives for health personnel proved successful in improving their performance, as judged by attendance rates as well as the quality and quantity of activities. This initiative also provided the district management with a tool for exerting pressure on health staff to improve their performance. The availability of independent NGO funds and a logistics team for construction of new infrastructure allowed the rapid initiation of new interventions at the district level without having to wait for disbursements of funds from the central level. This introduced a new dynamic of decentralised operational flexibility at the district level which improved access to care and support for people with TB-HIV.