Two hospitals being built in Afghanistan through U.S. reconstruction aid are financially unsustainable and cost five times as much as the ones they are replacing, U.S. inspectors have found. The same review also found a majority of Afghan provincial hospitals run by the U.S. government are also chronically understaffed.

The U.S. government’s lack of coordination with the Afghan government before construction resulted in the two new hospitals being far too expensive for the Ministry of Public of Health to operate on its own. One hospital is twelve times the size of its replacement and will outstrip the Afghan government’s health budget.

The two hospitals, financed by U.S. Agency for International Development, are the subject of a new investigative report released Tuesday by the Special Inspector General for Afghan Reconstruction.

“More than likely, better design planning for Gardez and Khair Khot would have produced more economical and practical hospitals and allowed for better use of U.S. appropriated funds,” the report said.

The two hospitals illustrate a larger problem throughout Afghanistan, where USAID has poured $236 million into a public health program the Afghan government cannot sustain once the U.S. leaves.

The hospitals in Paktia and Paktika provinces have cost the U.S. a total of $18.5 million to build and will cost millions more every year to run.

“USAID’s late coordination resulted in the construction of facilities that are larger — Gardez hospital is 12 times larger than the facility being replaced — than can be sustained, and increased estimated operating costs for the new facilities that are disproportionate to current costs,” the report said.

The existing 70-bed Gardez hospital, for instance, has an annual operating cost of $611,000. USAID estimates fuel costs alone for the new 100-bed hospital will be closer to $3.2 million, along with $1.1 million in operating costs.

“A Ministry official stated that they do not need such a large hospital, which will require additional staff for cleaning and security and further strain funding available for future hospital operations,” the report said.

The 20-bed Khair Khot hospital will replace the old district hospital and cost $587,000 for annual operation and maintenance, up from $98,000.

The inspector general’s office, called SIGAR, reviewed hospitals run by USAID in five provinces and found them routinely understaffed, with some vacancies persisting for years. Three of the five hospitals had no anesthesiologists, obstetricians and gynecologists, or pediatricians.

A shortage of doctors, low salaries and consistently late pay from the Afghan government has made filling open positions difficult, according to the report. Competition with private-sector employees further limits the number of doctors the USAID hospitals are able to hire.

USAID officials disagreed with the SIGAR’s findings and said the report focused too narrowly on its challenges, painting a poor picture of its success in Afghanistan’s “highly complex” public health system.