Gaza’s hospitals have been a flashpoint of fighting, claims and counterclaims.

Tens of thousands of people sought shelter in medical facilities after being driven from their homes by the risk of airstrikes.

But many have fled elsewhere as hospitals ran out of fuel and power and the fighting circled closer.

Al Shifa, the largest hospital in Gaza, is now surrounded by Israeli troops as gunfire and explosions rage around it.

The hospital’s last generator ran out of fuel at the weekend, leading to the deaths of at least 32 patients, including three babies, according to the Hamas-run Gaza health ministry.

Al Quds hospital is also now also closed to new patients. The Red Cross tried to evacuate about 6,000 people from the hospital but said its convoy had to turn back because of shelling and fighting.

Hospitals have protected status in wartime – but there are caveats to when this applies.

Here Sky News looks at what the rules are, and what both sides are saying.

Follow Israel-Gaza latest: Communications in Gaza could fail in two days

What are the rules on the protection of hospitals?

The International Criminal Court’s Rome Statute states it is a war crime for combatants to “intentionally direct attacks against… hospitals and places where the sick and wounded are collected, provided they are not military objectives”.

Under international humanitarian law (IHL) hospitals have protected status during war.

This means they cannot be attacked or otherwise prevented from performing their medical functions, according to the International Committee of the Red Cross (ICRC).

However, hospitals can lose those protections if they are used in a way that is harmful to the enemy – this includes being used to hide fighters or store weapons, the ICRC said.

But this does not give the other party free licence to attack, ICRC legal officer Cordula Droege said.

A warning must be given – first to stop the misuse of the hospital and then to allow evacuation of staff and patients if the misuse continues.

Any attack must be proportionate, Ms Droege added. If harm to civilians from an attack is disproportionate to the military objective, it is illegal under international law.

Also, using hospitals for military purposes is a violation of international humanitarian law, according to Amnesty International.

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What does Israel say?

Israel claims Hamas uses hospitals for military purposes – but has not provided verified visual evidence of this.

It says Hamas has built a vast underground command complex centre below al Shifa hospital, connected by tunnels.

Israel also claims hundreds of Hamas fighters sought shelter at al Shifa after the 7 October attack.

The IDF released footage on Monday of a children’s hospital that its forces entered over the weekend, showing weapons it said it found inside, as well as rooms in the basement where it believes Hamas was holding hostages.

“Hamas uses hospitals as an instrument of war,” said Israel’s chief military spokesman Rear Admiral Daniel Hagari from a room at the Rantisi Children’s Hospital where explosive vests, grenades and RPGs were displayed on the floor.

Israel also accuses Hamas of using ambulances to carry fighters, using this as justification for a strike on an ambulance convoy that officials in the Hamas-run health ministry said killed and injured scores of people.

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What does Hamas say?

Both Hamas and al Shifa hospital staff deny Israeli allegations militants are operating a command centre from within its grounds.

Ghazi Hamad, a senior Hamas official, rejected the Israeli claims about al Shifa as “false and misleading propaganda”.

“The occupying forces have no evidence to prove it,” he said. “We have never used civilians as human shields because it goes against our religion, morality and principles.”

In a statement on its Telegram channel, Hamas said the video of Rantisi hospital showed “fabricated scenes that misled public opinion”, adding that it was a “failed attempt” by Israel to justify the targeting of hospitals.

At al Shifa, spokesperson for the health ministry Ashraf al Qidra said Israeli snipers and drones were firing into the hospital, making it impossible for medics and patients to move around.

Israel said the east side of the hospital was a safe passage for people to leave al Shifa, but people who tried to leave said Israeli forces had fired at evacuees and that it was too dangerous to move the most vulnerable patients.

The World Health Organisation said there was “no safe passage out of the hospital”.

Goudhat Samy al Madhoun, a healthcare worker, told the AP news agency that about 50 people left on Monday and were fired at several times, wounding one man who had to be left behind.

Read more:
Gaza surgeon gives harrowing account of child amputation
Palestinians stream onto Gaza highway as Israeli forces strike near hospitals

What has the international response been?

The international NGO Human Rights Watch has called for the attacks on “medical facilities, personnel, and transport” to be investigated as war crimes.

Israel’s claims about Hamas activity in hospitals are contested, Human Rights Watch said.

“Human Rights Watch has not been able to corroborate them, nor seen any information that would justify attacks on Gaza hospitals,” it said.

It added that Israel’s general evacuation warning to hospitals in northern Gaza was “not an effective warning” because it did not account for the safety needs of patients and medical staff.

The 27 European Union nations have jointly condemned Hamas for what they described as the use of hospitals and civilians as “human shields”.

US president Joe Biden said hospitals “must be protected” as he called for “less intrusive action” in relation to hospitals.

Insecurity Insight collects data on attacks on healthcare in Israel and Gaza. Its data – which it notes is not complete – from 7 October to 5 November records 219 incidents of violence against or obstruction of access to healthcare facilities in Gaza and 10 in Israel.

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