April 2024


Samantha Ostenso, Program Assistant, Grantmakers In Health
Kate Treanor
, Senior Program Director and Strategic Advisor, Grantmakers In Health

In 2019, MacKenzie Scott announced that she was stepping into the world of philanthropy to give away her multi-billion-dollar fortune “until the safe is empty” (The Giving Pledge 2019). She has kept her word—to date, she has given away $16.5 billion (Yield Giving 2024). Her initial process for choosing which organizations would receive grants was shrouded in mystery. From 2019 to 2023, Scott used a process she termed “quiet research” to identify possible grantee organizations. The lucky organizations received a call from Scott’s consultants, who let them know they were receiving a grant for immediate use however they would like to spend it. In the Fall of 2022, Grantmakers In Health (GIH) became one of those grantee organizations, along with more than 20 health foundations. Two additional GIH Funding Partner organizations received gifts in 2020 and 2021, respectively.

Spurred by the receipt of this gift, GIH convened the health foundations included in the Fall 2022 tranche of Scott’s grantmaking. Together, we explored the various aspects of receiving and managing these large, unrestricted grants. The convenings, which took place over several months, were designed to explore the commonalities among this group of foundations, the administrative aspects of accepting Scott’s gifts, and foundations’ plans to distribute the funds. This article shares key insights gleaned from our conversations about the challenges and opportunities presented by these transformative gifts.

Scott’s Giving Strategy

MacKenzie Scott’s giving strategy is rooted in her belief that “people who have experience with inequities are the ones best equipped to design solutions” (Scott 2020). To fulfill her pledge to give away the bulk of her wealth, Scott engaged The Bridgespan Group to identify nonprofit organizations generating impact on a range of issues including climate change, economic mobility, gender equity, public health, and racial equity. This work has resulted in more than 1,900 nonprofit organizations receiving large, unrestricted grants (Yield Giving 2024).

The criteria used for selecting grant recipients remains unclear. However, as we put the puzzle pieces together, we believe Scott and her team viewed health-focused foundations as effective vehicles to reach communities throughout the country. The foundations that received gifts in 2022 are spread across 19 states and have several common characteristics and areas of focus.

First, the majority of foundations are place-based funders, including health conversion foundations and community foundations, with grantmaking priorities that reflect the diverse interests and needs of the geographic areas they serve. They are also well positioned to successfully engage a wide range of stakeholders and to invest funds directly in their communities.

Another commonality among this group of foundations is their shared goal of creating healthy, inclusive communities. Despite working on different concerns—like strengthening the health care workforce, ensuring access to nutritious food, and addressing the social determinants of health—each is deeply committed to advancing health equity.

Finally, most of the health-focused foundations that received gifts from Scott in 2022 are in states with large rural areas including Alaska, Georgia, Kansas, Kentucky, Louisiana, Maine, Missouri, Montana, New Hampshire, New Mexico, Texas, Virgina, and West Virginia.  Disadvantaged by geography, rural communities face health disparities from factors such as the lack of economic opportunities, limited broadband service, and higher rates of poverty. They also struggle with a growing shortage of health care services caused by hospital closures, provider shortages, and long travel distances to receive care.

Receiving Large, Unrestricted Grants

MacKenzie Scott’s gifts to this group of health-focused foundations took different forms: cash, stock, and in the case of one foundation, real estate. The administrative aspects of receiving such gifts were not always straightforward. The private foundations first needed to determine how they could receive the gifts. One foundation, for example, accepted its gift through an affiliated public charity that serves as a fiscal intermediary for several of its established programs. Two other private foundations accepted the funds into their corpus. On the other hand, foundations set up as public charities already had processes in place to receive contributions in various forms from private donors like Scott. Additionally, for foundations that received stock, decisions on when to sell came into play.

Other administrative challenges of large, unrestricted grants include the donation’s effect on foundation payout levels, as well as determining a timeframe for dispersing the funds. Many of the foundations participating in the GIH convenings anticipated distributing their funds within two to five years, but some leaders noted it could take longer.

There was, however, an important shared vision among this group of philanthropic leaders: they would give the funds with the same spirit in which they were received. Over the course of our convenings, they articulated this desire in several ways including applying trust-based philanthropy; engaging in participatory grantmaking; giving unrestricted, multi-year grants; and reducing or eliminating grantee reporting requirements.

A Transformational Opportunity

After receiving Scott’s gifts, each foundation went through its own decision-making process to determine how the funds would be used. This led to deep conversations at the board and staff levels about the unique opportunities presented by the donations. Several foundations also sought community input about how to use the funds. Danville Regional Foundation in Danville, Virginia, engaged with residents through existing community councils, while the Mary Black Foundation in Spartanburg, South Carolina created a new community committee to make recommendations. Maine Health Access Foundation in Augusta, Maine, took a different approach. Using charrettes, a type of participatory planning process, stakeholders identified issues where the foundation could “move the needle.” A design team made up of foundation board and Community Advisory Committee members, staff, and consultants was formed and collectively they identified three areas of interest.

The large, unrestricted grants given by MacKenzie Scott are widely seen as transformational by nonprofit leaders (Buteau et al 2022). For health foundations, they present distinct opportunities to advance their missions by increasing investments in current areas of focus, expanding into new areas of work, implementing innovative strategies, and making “big bets.” The grants also allow foundations to strengthen their internal capacity as well as the capacity of nonprofits and other stakeholder organizations. During our discussions, there was broad acknowledgement of foundations’ intent to offer unrestricted grants as a strategy to build the capacity of local nonprofits as a way to “pay it forward.”

Ultimately, we found that the action plans created by this group of foundations reflect the unique needs of their communities. During our discussions with foundation leaders, we heard how they strove to balance the desire to quickly get funds “out the door” with the desire for stakeholder input and development of a thoughtfully constructed, longer-term strategy.

Maine Health Access Foundation’s inclusive planning process, for example, resulted in a plan to create a coordinated health justice movement throughout the state, to invest in transformative ideas that can generate systemic change, and to continue support for the foundation’s existing priorities. This approach blends support for current priorities with investments in new areas and innovative ideas and is one that several other health foundations are also using.

Of the health foundations using a portion of their grants to invest more deeply in current funding priorities, several leaders noted that their organizations had recently completed strategic planning processes, with Scott’s gifts viewed as validation that their plans are headed in the right direction. The Rapides Foundation in central Louisiana is increasing the “dosage” given for priority areas. It also plans to substantially increase its support for the area’s Nurse-Family Partnership, a nonprofit that provides support for pregnant women and their babies. Leaders at Montana Healthcare Foundation are thinking strategically about how to move deeper into work addressing the social determinants of health. Paso del Norte Health Foundation in El Paso, Texas viewed the Scott gift as an opportunity to augment work within its current areas of focus by supporting innovative ideas, programs, or organizations and identifying opportunities to scale promising approaches.

Two foundations shared their plans to extend their existing areas of focus with significant grants or initiatives. The grant from Scott allows the Health Foundation for Western and Central New York to expand its work on rural health and to implement a trust-based approach to grantmaking. The foundation launched the Transform Rural Health campaign to raise awareness of health disparities in rural areas and to serve as a call to action for system change. The foundation also awarded unrestricted grants to six rural health networks to help advance rural health equity in several upstate New York counties. Sunflower Foundation in Topeka, Kansas, is using a quarter of its funds from Scott to improve food security in the state. The foundation is working on a plan to construct a fresh-food storage facility in the Western part of the state.

Other health foundations are “stretching” into new strategies. In Montana, leaders at Headwaters Foundation are considering how the foundation can support leaders at the neighborhood level or those not affiliated with established nonprofits, particularly in tribal communities. Meanwhile, the Montana Healthcare Foundation is making plans for its first impact investment to a native Community Development Financial Institution (CDFI). Mat-Su Health Foundation in Wasilla, Alaska is partnering with a local credit union to lower interest rates for nonprofit organizations applying for loans.

Staff at the Endowment for Health in Concord, NH are also integrating new strategies—specifically trust-based philanthropy and participatory grantmaking—into their work. One of the Endowment’s first actions was to make unrestricted grants to trusted BIPOC-led partner organizations. And there are plans to expand this grantmaking strategy over the next five years. Additionally, the board earmarked a portion of funds for grants to community advisory groups that will then make decisions about what to fund in their own communities.

Several of the health foundations that received gifts from Scott in 2022 plan to expand into new areas of work that they believe will advance health in the communities they serve. In considering areas of work that could be most impactful for the Kansas City region, the board of Health Forward Foundation decided to invest a portion of the funds in developing career pathways for people of color to enter health professions and creating a health sciences talent pipeline.

After digging into South Carolina’s health data and soliciting community input, Mary Black Foundation plans to invest in behavioral health, an area of needed investment. While this is a new focus of work for the foundation, it is viewed as a companion to the foundation’s existing work to reduce health disparities. Episcopal Health Foundation in Houston, Texas, received its gift from Scott as it was embarking on a new strategic planning process. While some of the new funds will go toward current priorities, the foundation sees a clear opportunity to invest in new areas identified through the strategic planning process: food security, maternal health, and diabetes prevention. Scott’s gift will allow the foundation to move “deeper and faster” into those new areas.

Impactful Giving

Among the health-focused foundations participating in GIH’s convenings, the gifts from MacKenzie Scott are seen as a validation of their work, of their collaborative approaches to advancing health, and of their dedication to building more equitable and resilient communities. However, these gifts do not come without challenges. Decisions about how to leverage the strategic opportunities presented by the gifts, as well as the processes for administering grants and measuring their impact, will continue to be considered by each foundation. Their internal operations are also affected, with each foundation left to decide how to manage an increased level of payout, which for some is more than a million dollars annually.

Scott’s giving strategy is distinctive, and the size of her gifts challenges traditional ideas of “big” giving by high-net-worth individuals (Buteau et al 2022). It’s an approach that other donors can apply as they seek to advance their goals. Place-based health foundations are uniquely well suited to act as conduits for those donors seeking to catalyze change at the community level.


Buteau, E., Buchanan, P., Lopez, M., et. al., Giving Big: The Impact of Large, Unrestricted Gifts on Nonprofit Endowments. Center for Effective Philanthropy: Cambridge, MA, 2022.

Scott, MacKenzie. “116 Organizations Driving Change.” Medium, July 28, 2020.

The Giving Pledge, “Pledge Letter: MacKenzie Scott.” May 25, 2019.

Yield Giving, “Yield Giving.” Accessed on January 8, 2024.

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