WASHINGTON – The Trump administration spent $200 million to send more than 8,700 ventilators to countries around the world last year, with no clear criteria for determining who should get them and no way to keep track of where many ended up, according to a new report from the Government Accountability Office.

The effort, driven by the Trump White House, was an unusual top-down initiative with little decision-making by experts at the U.S. Agency for International Development, which carried out the administration’s orders. Former president Donald Trump last year boasted about U.S. success in manufacturing the machines and declared the U.S. “the king of ventilators,” promising donations to foreign countries.

Staff on the White House’s National Security Council communicated to the aid agency “U.S. government decisions regarding ventilator donations, including the recipient countries, quantities, and manufacturers,” the GAO found.

“These ventilators were not in State or AID’s strategic plan,” said David Gootnick, director of international affairs and trade at GAO. “They could not articulate for us the criteria they used for what ventilators went to what countries.”

The GAO was unable to identify how the Trump White House made its decisions on ventilator allocations, and White House officials did not respond to the watchdog’s questions, which came before President Biden took office last week. For instance, while Sri Lanka had just three new coronavirus cases per day when it received 200 ventilators, Bangladesh, which had 1,409 new cases, received just 100 of the machines, the report found.

Relatively wealthy recipients such as Italy and St. Kitts and Nevis also received ventilator donations, as did tiny island nations such as Nauru and Kiribati, which have yet to report a single coronavirus case.

ProPublica reported last year that the ventilator donation effort was marked by dysfunction and little clarity on how countries were chosen for the donations. The GAO’s findings largely confirmed that report and provided new details, finding that USAID ultimately spent $200 million to send 8,722 ventilators to 43 countries.

Throughout last year, USAID and White House officials frequently publicized the donations on social media, sharing pictures of large boxes plastered with USAID’s logo ready to be shipped out.

USAID and the State Department did not immediately respond to requests for comment, and a White House spokeswoman referred questions to them. The companies that manufactured the ventilators donated by USAID – Vyaire Medical, Zoll Medical and Medtronic – and Chemonics, the development consulting firm that USAID paid to deliver the ventilators, also did not immediately respond.

“USAID-donated ventilators have equipped medical providers to deliver quality care that is saving lives around the world,” the agency said in a response to GAO’s findings, sent to the watchdog on Jan. 6.

The process revealed in the report runs counter to how foreign assistance usually works. Although officials at the White House may set priorities for foreign aid, Republican and Democratic administrations alike have generally left the details of the aid, how it is distributed, and on what basis it is allocated to experts within USAID, which has local missions around the world that work closely with their host countries to determine needs.

Global health experts say ventilator donations, while flashy and attention-getting, are often less useful than more basic health aid, such as simple oxygen delivery or protective personal equipment. Ventilator manuals often come in just a few major languages, and the machines require expert maintenance and operation – obstacles for stretched hospital staff in poor countries.

“I don’t think it’s at all just USAID,” said Rebecca Inglis, a physician specializing in intensive care who researches care for critically ill patients in places with few resources. “Donor organizations around the world have failed to realize that a ventilator is nothing without the people who can operate it safely and without the maintenance contracts.”

USAID said in its response to GAO that its ventilator donations included warranties, service plans, initial supplies of accessory equipment, and training.

“USAID’s investments in training are boosting the capacity of frontline workers to deliver quality care to patients in need in dozens of countries,” the agency said.

USAID also questioned whether the number of coronavirus cases is the best metric to judge the ventilator donations, given the pandemic is “not static.” The agency added that the Trump administration’s decisions on ventilator allocations were based “in part” on USAID data.

As of December, USAID and the State Department had very limited visibility into where the ventilators actually are, Gootnick said, making it difficult to know whether the aid it gave out is being used appropriately. In only 12 of 43 countries did the government have a fairly good idea where the ventilators are, he said.

USAID is now trying to figure out where the ventilators went, the report said.

While USAID rules typically require officials to monitor whether foreign aid efforts achieve their intended goals, agency officials told the GAO that it considers the ventilator donations exempt from some of those monitoring requirements.

The cost of donating the machines came out of several extra pots of money, totaling some $685 million, that Congress provided to the State Department and USAID last year to help combat the coronavirus pandemic globally, the GAO found.

In 21 of the 43 recipient countries, the cost of ventilator donations made up more than half of the extra covid-19 funding that USAID provided to those countries, the GAO found. In El Salvador, Paraguay, Egypt, and several other countries, the entire coronavirus aid budget was consumed by the ventilator donations.

“When I’m sitting there writing a budget for how a country should spend its covid money, you definitely wouldn’t dedicate that high a proportion to isolated procurement of mechanical ventilators,” Inglis said.

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