Medical imaging equipment can have tremendous clinical value, and is in great need in the developing world. Like all equipment, the most basic X-ray imaging systems require complex considerations to maintain quality, most notably maintenance and repair. The costs of maintenance and repair generally exceed the costs of purchase; thus donating a piece of imaging equipment does not necessarily save the recipient hospital money. Due to this reality, in addition to failure in planning and regulating these processes, nearly 50 % of all donated X-ray equipment is out of service. Donating medical imaging equipment often leaves the recipient hospital with additional financial burdens but without additional clinical abilities. This article reviews considerations for improving the probability of a successful donation of medical equipment.