In an effort to improve delivery of basic health services, the government of Pakistan has contracted in management of lower level health facilities with a group of government managers in a unique model that seconds the managers to an NGO to give them more authority to make decisions. The increased accountability created by a need to prove themselves, and flexibility to make management decisions including hiring and transfers, has enabled the new managers to improve availability of medicines and supplies, hire doctors on contract, and improve provider performance through increased monitoring. The changes have dramatically increased utilization of services at facilities.