People Operations Gap in Global Health

By Berke, Tony Senanayake @ 2026-09-11T13:14 (+19)

Conflicts of Interest: Berke Çelik is the director of Health Progress Hub (HPH), a consultancy providing recruitment and scaling support to global health organizations. If funders or organisations act on our recommendations, HPH could benefit financially.

Tony Senanayake is the CEO of Fortify Health, a non-profit working to reduce anaemia in India, and sits on the boards of other organisations of the kind discussed in this post. He is also an advisor to HPH.

This post reflects our personal opinions and not those of Fortify Health, HPH, or any other associated organisation. We used AI tools for copyediting; the ideas and analysis are our own.

A wave appears to be coming. Coefficient Giving’s $1 billion commitment to GiveWell is perhaps the first ripple in what is a very exciting water body.

This wave could enable many cost-effective organisations to deliver impact at a far greater scale. However, surfing a standard two-foot wave is one thing, being prepared to surf this incoming seismic wave appears to be another altogether. In order to surf this incoming wave, organisations must have the surfboard - people infrastructure - capable of handling it.

Our argument is that absorbing and deploying any step-change in funding well depends on people operations infrastructure - the systems by which an organisation attracts, retains, develops, and deploys its people. This infrastructure must be built well before funding arrives. The organisations with best equipped people operations tend to be large ones, with established recruitment pipelines, HR functions, and management structures, and funding may flow to them partly for that reason. But some of the most exciting work in global health comes from small, young organisations that match (if not exceed) larger ones on impact per dollar and have very limited people operations infrastructure.

Our sense is that, by default, funding will tend to follow absorptive capacity, and that absorptive capacity and cost-effectiveness overlap less than we would want. This post is an attempt to think through what follows.

We make three claims, then close with suggestions:

1. People operations are a key determinant of whether organisations can effectively absorb funding.
2. Absorbing significantly more funding requires a step-change in how organisations approach people operations.
3. The ecosystem systematically underinvests in people operations.

We lay out some suggestions on tractable solutions for organisations, funders and ecosystem supporters. Many of the forces at play will require a more general mindset shift around the importance of early and deep investments in people operations, similar to what we have more broadly seen in the reimagination of the role of ‘overhead’ costs in the non-profit sector of the past decade.

People operations are a key determinant of whether organisations can effectively absorb funding

There are cost-effective interventions. Whether they achieve their estimated impact depends on implementation fidelity: whether the programme is delivered as designed.

Implementation fidelity ultimately depends on the organisation delivering it: the staff, managers, and systems that turn funding into delivered goods and services to beneficiaries. This holds even for interventions that look operationally simple. For example with GiveDirectly, the theory of change is powerful in its simplicity: providing unconditional cash transfers. One would assume that people operations for such an organisation may not be a binding constraint. However the team employs between 750 - 1000 people, dedicating ~23% of total costs to people ($31M personnel expenses out of $130M total expenses in FY24 financial statement). The organisation is efficient, and even then, it is running a very sizeable people operation.

Good people operations do not necessarily mean a large staff. Against Malaria Foundation deploys over $100 million a year with a core team of only 17 people (remarkable), outsourcing delivery to distribution partners and leaning on volunteers and pro bono support. Moving that volume of funding through a team of 17 is only possible with well-designed, carefully planned people operations and is the very extreme exception, not the rule.

Most small organisations in this ecosystem, however, have small staff size without AMF's systems behind them. In AIM's 2025 internal survey of its incubated charities (unpublished; figures shared with the authors and cited with AIM's permission), the median organisation employed around 4 FTE. Although a small team is not necessarily a problem in itself, failing to grow it when you need to may be. Staffing was the first of five themes among the challenges AIM-incubated organisations reported: difficulty identifying and attracting top talent, especially for senior leadership, along with challenges in performance management. And that is before the wave arrives. Absorbing significantly more funding means hiring faster, managing more, and retaining longer, with systems that are already not up to the task.

Absorbing significantly more funding requires a step-change in how organisations approach people operations

As Toby Ord stated, “there is a moral imperative to fund the most cost-effective interventions. … The main effect of understanding the moral imperative toward cost-effectiveness is spending our budgets so as to produce greater health benefits, saving many more lives and preventing or treating more disabling conditions.” There are broadly two ways that this can be considered:

1. Cost-effectiveness for a grant: How do we grow this year's programme at minimum additional cost?
2. Cost-effectiveness at scale: What does the organisation that treats 100x or 1000x as many beneficiaries need to look like — and what must we build now to become it?

The moral imperative moves us towards the second definition, as it is only under the scaled model that we unlock the full benefits of cost-effectiveness to reach magnitudes more beneficiaries. Unfortunately however, cost-effectiveness is often focused on the former definition, which can lead to irrational, short-term frugality that often surfaces in underinvestment in people operations.

As Nick Allardice put it, “organizations break as they scale,” and he goes on to highlight the following ways that they can break: decision rights, coordination, smart heroics, quality control, risk, culture and leadership … notice the common factor to all of these … people! And as the headcount grows, so does everything that can go wrong with it.

The ecosystem systematically underinvests in people operations

Surveys from the development sector clearly identify the relative weakness of people operations. In the Stanford Survey on Leadership and Management in the Nonprofit Sector 35% of organisations reported struggling with attracting, retaining and developing talent. In the Center for Effective Philanthropy's 2025 survey, nearly two thirds of leaders reported difficulty filling vacancies in the past year.

A 2016 Rippleworks survey of social enterprises, cited in Duke CASE's Scaling Pathways series, found fundraising and talent(ed people) to be the two biggest challenges, but while fundraising tends to ease over time, talent gets harder, and for later-stage enterprises talent eclipsed fundraising as the top challenge.^[1]  

The evidence-oriented global health ecosystem shares these symptoms. In AIM's 2025 survey of its incubated charities, 31% of organisations disagreed that they have strong HR systems, making it one of the three weakest-rated areas of organisational set-up, and the only capability for which post-pilot organisations rated themselves worse than pre-pilot ones. AIM's own reading is that this likely reflects growing staff size and complexity, which is our point: HR demand scales with the organisation, and the investment does not keep pace.

This challenge matches the wider nonprofit sector, but this ecosystem has a contributing cause of its own: a focus on short-term, grant-based cost-effectiveness. Cost-effectiveness is a good target; its short-term version, however, rewards visible programme spending over invisible people infrastructure. The underinvestment it produces takes recognisable forms, particularly among smaller organisations:

• Lack of focus on leadership capacity beyond founders:
  • Healthy growth depends on managers and leadership staff. Founders can hold operations together at a small size, but growth requires leadership capacity beyond them, and organisations underinvest both in this capacity and in the recruitment work of finding it.  In the same AIM survey we refer to above, hiring senior staff was the top constraint for post-pilot organisations (jointly with hiring local talent), with 41% rating it a high concern, and staffing was the first of five themes among reported challenges.
  • Leadership investment and pay - There is a direct incentive to underpay leaders in order to arbitrarily inflate cost-effectiveness. More generally, there have been policies that have incentivised frugality, especially within the global health startup space, although some of these are relaxing.
• The Non-Profit Starvation Cycle - The negative feedback loop of poor incentives with limited capacity:
  • Scaling often demands unsexy, essential work: building the systems, SOPs, and processes that let a proven intervention grow. This work is hard to fundraise for, since unrestricted funding for overheads remains persistently scarce. The problem compounds because the skills needed to scale a health intervention are often orthogonal to the entrepreneurial skills that got it piloted and proven cost-effective in the first place. Pair a lack of resources with a lack of incentives, and under-investment is the natural result.
• Underinvestment in retention and team development
  • Retention determines whether an organisation can grow its own managers and keep the knowledge that lives in its people: relationships, trust, how delivery actually works.
  • Developing people has delayed, diffuse returns, and many organisations deprioritise it: few promotion pathways, little progression, limited training. Staff who want to grow often leave, and scale-up roles are filled externally at higher cost.

Some outcomes we are concerned about

The incoming wave of funding will save and improve a great number of lives. But the commitment of this ecosystem was never to do good; it is to do the most good we can with what we have. To get there, we believe a step-change in how organisations and funders approach people operations is needed, and urgent. Without it, the following outcomes seem likely to us:

• Many organisations running interventions with substantial room for scale will not receive funding at the level their cost-effectiveness warrants, because they lack the people infrastructure to absorb it. For an organisation saving a life for $5,000, the difference between absorbing $5 million and $10 million a year is roughly a thousand lives, every year.
• Some organisations will receive significant funding without the people operations systems to deploy it well, and will deliver less impact per dollar than their track record promised.
• Funding will tend to concentrate in large organisations with existing absorptive capacity. Early-stage organisations, whose systems are often still unbuilt at the point their cost-effectiveness is proven, are likely to be underweighted. So are local organisations, which have had limited access to the non-programmatic funding needed to build operational infrastructure in the first place.
• The gap between what the wave achieves and what it could have achieved will not be measured. Foregone impact appears on no budget, and what appears on no budget gets fixed by no one.

These outcomes are not inevitable. Below, we suggest tractable steps at the level of organisations, funders, and ecosystem supporters.

Potential Solutions

The problems above are solvable, and much of the solving can start now, before the wave arrives. We group the steps by who can take them: organisations, funders, and ecosystem supporters.

Organisations

• Develop a long-term strategy for cost-effectiveness at scale
  • Identify the people and skills required to implement at scale: what systems are needed to recruit, manage, and retain people at the larger size, and who will build and maintain them?
  • For each of these capabilities, decide deliberately whether to build in-house, contract out, or defer, and revisit as the organisation grows. Outsourcing can look cheap and quick, but it can prevent building capabilities a rapid scale-up would require; the failure mode is deciding by default rather than on purpose.
  • Recruit board members and advisors with prior scale-up experience: a low-cost way to bring in people who have answered these questions before, and to build the governance mechanisms growth will require. The EA Good Governance Project helps (eligible) organisations find and select board members at no cost.
• Prepare for the shift from founder-led to manager-led operations.
  • Early on, operational knowledge and decisions sit with founders; at a larger size this stops working, and the shift rarely happens on its own.
  • Hiring mid-level or senior managers with prior scale-up experience is, in our opinion, one of the investments this shift requires, and one that organisations tend to defer longest. Jack Lewars discusses this well here.
• 15% Leadership / 15% Operations - consider this heuristic for headcount, especially at the early stages of a scaling journey.

Funders

• Consider funding absorptive capacity before the grantee is asked to absorb. Many organisations may soon be asked to deploy far more funding than they were built for, and the people operations infrastructure may not yet exist. It is cheaper to build before the funding arrives than after it starts straining the organisation. Some approaches could include:
  • Explicitly pulling out indirect and executive people-related costs when requesting budget information
  • Nudging small and medium-sized organizations in scaling journeys to increase overhead apportionment
• Consider assessing the organisation's room for funding, not only the intervention's: can its management structures absorb the additional staff that more funding requires? What is the strength of the team's existing HR or people function? Does the organisation have a proven track record of hiring and retaining talent?
• Consider supporting funding vehicles dedicated to this transition. Organisations will keep reaching the proof-of-concept-to-scale point as long as the ecosystem keeps incubating them; standing infrastructure beats handling each case from scratch. Possible forms:
  • Dedicated funds that identify organisations capable of deploying significantly more funding and fund what their scale-up requires, accumulating expertise generalist funders cannot. Ultra Philanthropy's Mid-Stage Global Health Fund may be a relevant model here.
  • Regranting programmes: capacity grants are often too small for large funders' pipelines; intermediaries can make many such grants at a granularity major funders cannot.
  • Venture philanthropy: grants paired with hands-on operational support. The Draper Richards Kaplan Foundation is a clear example: three years of unrestricted funding paired with a board seat and dedicated capacity-building support across leadership, organisational development, and fundraising.
• Reward investment in people operations, whichever form it takes. Funders can use money to shape behaviour. That could mean rewarding organisations that bring in senior operators early, invest in management training, or use high-quality external support where building in-house does not yet make sense.

Ecosystem supporters

The suggestions above ask organisations to build and funders to pay. Between them sits a third group: organisations whose purpose is to make that building cheaper for everyone else. Fiscal sponsors such as SparkWell and Rethink Priorities' Special Projects already do this for legal and financial infrastructure. People operations consultancies such as Impact Ops and Health Progress Hub (see the disclosure at the top) do it for recruitment and operations. We believe such organizations have a key role to play in how well the wave is absorbed. Our suggestions for them follow.

• Help organisations decide what to internalise, not only what to outsource.
  • There is no general answer: it depends on size, stage, and how context-specific the function is. Support organisations are often better positioned than their clients to know which functions transfer poorly, and should say so, including where the honest answer reduces their own revenue.
• Build support models that let clients become independent of you.
  • Document processes and train internal staff alongside delivery, so outsourced functions can be internalised when the organisation is ready. SparkWell, which sponsors projects for 6–24 months and then graduates them into independent entities, is a good example (disclosure: HPH is a SparkWell project).
• Build shared, public resources for the proof-of-concept-to-scale transition, rather than keeping know-how proprietary to individual consultancies.
  • Good precedents exist: CARE / IDinsight’s Scaling Playbook, Spring Impact's open-source Scaling Impact Toolkit distils lessons from supporting 300+ organisations into free, practical guides, and Duke CASE's Scaling Pathways series publishes stage-by-stage playbooks, including on talent, drawn from social enterprises that have scaled. Comparable open resources tailored to people operations in evidence-based global health largely do not exist yet.
• Bring experienced operations professionals into the ecosystem. The evidence-based global health ecosystem's talent pipelines run towards research and founding; the organisations delivering interventions run on operations, and field-building to channel people into these roles has had no comparable investment.
  • Efforts in this direction are emerging: organisations such as High Impact Professionals, Scale Wise and Consultants for Impact improve the global health ecosystem's access to experienced operations professionals.
  • Community-builders also have a role: EA South Africa and EA Nigeria run a global health fellowship that builds a pipeline of talent from the countries where most delivery happens (disclosure: HPH is a partner in the fellowship). Still, we believe the pipeline for senior operators remains weak, and these are the roles that will matter most during this wave: heads of people, COOs, and chiefs of staff.

If you are planning to hire, or want to talk through any of the questions in this post, you can fill in Health Progress Hub's expression of interest. See the conflicts note at the top.

1. ^{^}

    A separate survey by the Scaling Pathways team of over 100 social enterprises from the Skoll Foundation and USAID Development Innovation Ventures portfolios found the same: talent among the top challenges cited, including by organisations already operating at significant scale.