Before the first airstrike of October 7, 2023, Gaza’s healthcare system was already running on borrowed time. Thirty-six hospitals served a population of roughly 2.3 million people compressed into 365 square kilometers — one of the most densely populated territories on earth. The wards were full, the generators were temperamental, and the medicine shelves were never quite stocked. This was not the result of mismanagement alone. It was the predictable output of seventeen years of blockade, three major military offensives, and a permit system that turned a referral to a cancer specialist into a bureaucratic ordeal that could — and sometimes did — end in death.
Understanding what Gaza’s hospitals were before October 2023 matters, because it is the baseline against which the subsequent collapse must be measured. A system that was already fractured is very different from one that was functioning and then destroyed. Both things are true of Gaza: the system was broken before, and it was then obliterated.
A System Built for Less, Strained by More
The thirty-six hospitals operating in Gaza prior to October 2023 included facilities run by the Palestinian Authority Ministry of Health, Hamas-affiliated management, UNRWA, and a handful of NGOs. In total, the system offered approximately 3,500 hospital beds, yielding a bed-to-population ratio that the World Health Organization assessed as critically inadequate. The WHO’s monthly Health Cluster Bulletins — published through its Jerusalem office and in coordination with OCHA oPt — consistently flagged bed shortages, equipment deficits, and staffing gaps as structural, not incidental.
Gaza’s largest and most internationally recognized facility, Al-Shifa Hospital in Gaza City, functioned as the territory’s de facto tertiary referral center. Built during the Egyptian administration of Gaza and expanded over subsequent decades, Al-Shifa housed departments for surgery, oncology, pediatrics, cardiology, and emergency medicine. It was the institution patients were transferred to when district hospitals could not cope — which was often.
The Indonesian Hospital in the north, the Nasser Medical Complex in Khan Younis, and the European Gaza Hospital in the southern governorate completed a loose hierarchy of major facilities. Below them sat a network of primary health care clinics, many operated by UNRWA, providing routine care to Gaza’s large refugee population. By 2022, UNRWA was running 22 health centers across the Strip, handling millions of patient visits annually.
Chronic Medicine Shortages: The 40 Percent Gap
Every month, Gaza’s Ministry of Health published a medicines and disposables shortage list. Month after month, the figures told the same story. The WHO and OCHA oPt documented that Gaza’s essential medicines stockpile regularly fell to levels covering fewer than three months of need, and frequently far less. In multiple reporting periods between 2018 and 2023, WHO data showed that more than 40 percent of essential medicines listed on the Palestinian standard formulary were either completely out of stock or available in quantities below one month’s supply.
The categories most affected were not obscure specialty drugs. They included antibiotics, anesthetics, chemotherapy agents, and dialysis consumables — the materials without which routine surgery becomes dangerous, cancer treatment halts, and kidney failure becomes a death sentence within weeks. A 2022 WHO situation report noted that oncology drugs and renal dialysis supplies were among the items most persistently at critically low levels.
Gaza had no functioning capacity to manufacture pharmaceuticals domestically. Every medicine that entered the Strip came through the Kerem Shalom crossing or, in smaller quantities, the Rafah crossing with Egypt. Both crossings were controlled by parties outside Palestinian authority. Delays — whether imposed deliberately, as collective punishment critics argued, or as a consequence of closure during military escalations — translated directly into patient harm. Medical equipment was subject to Israel’s dual-use goods policy, which classified a broad range of medical items as potentially militarizable and thus subject to restriction or prohibition. B’Tselem and Gisha documented cases in which parts for dialysis machines and imaging equipment were delayed or denied under this framework.
Cancer, Dialysis, and the Permit System
For Gaza’s cancer patients, the geography of occupation imposed a particular cruelty. Gaza had limited radiation oncology capacity and no bone marrow transplant capability. Patients requiring those treatments — or specialist consultations unavailable in the Strip — needed referrals to hospitals in the West Bank, East Jerusalem, or Israel. To make that journey, they required an exit permit issued through the Israeli military’s Coordination of Government Activities in the Territories (COGAT).
The permit process was documented extensively by Gisha — Legal Center for Freedom of Movement and the WHO’s monthly patient referral reports. The WHO tracked both the number of permit applications submitted and their outcomes. The data revealed a system riddled with delays and denials at a rate that advocacy organizations and health researchers described as incompatible with the right to health under international law.
In 2022, WHO data showed that roughly 15 percent of permit applications from Gaza patients were either denied or received no response — effectively a denial — in time for the scheduled appointment. For cancer patients, a missed appointment could mean a missed chemotherapy cycle. For children requiring cardiac surgery, it could mean a procedure performed too late. The permits also had to be obtained not just for the patient but often for an accompanying adult, and security screenings could add weeks to a process that the illness could not afford to wait out.
Patients on dialysis faced a different, more immediate arithmetic. Gaza had dialysis centers — the main facility at Al-Shifa and units in several other hospitals — but they operated under persistent shortages of consumables: dialysis tubing, bicarbonate solution, needles. Approximately 1,000 patients in Gaza were dependent on dialysis before October 2023, requiring treatment three times a week. Any disruption to supplies — a crossing closure, a delayed shipment — set that clock ticking in a very concrete way. OCHA oPt reported on shortages of dialysis supplies repeatedly in its bi-weekly Humanitarian Situation Reports throughout 2021, 2022, and into 2023.
Power, Fuel, and the Infrastructure of Crisis
Gaza’s electricity crisis was inseparable from its healthcare crisis. The territory’s single power plant operated at a fraction of its capacity, and residents received between four and twelve hours of electricity per day depending on the period. Hospitals were legally and operationally required to maintain backup generators — but generators require fuel, and fuel was itself subject to import restrictions and periodic shortage.
The WHO and OCHA documented multiple instances in which Gaza’s hospitals came within hours of running out of fuel, forcing the suspension of surgeries and the shutdown of ICU equipment. In May 2021, during the eleven-day military escalation, Al-Shifa Hospital publicly warned that its fuel supply would last fewer than 24 hours. The warning was repeated in 2022 and became a grim refrain. Healthcare workers described making clinical decisions — which operating room to power, which incubator to prioritize — that no clinician should ever have to make.
After October 2023: From Fragility to Rubble
The October 7, 2023 Hamas attack on southern Israel and the Israeli military campaign that followed did not encounter a resilient system. They encountered one already at the edge. What followed was the destruction of that edge entirely.
By early 2024, the WHO confirmed that the majority of Gaza’s hospitals had been damaged or rendered non-functional. Al-Shifa Hospital — the system’s anchor — was raided by Israeli forces in November 2023 and again in March 2024, operations that the Israeli military said targeted Hamas military infrastructure within the compound. By April 2024, WHO Director-General Tedros Adhanom Ghebreyesus stated that Al-Shifa had been “destroyed” and was no longer functional as a hospital. The WHO reported that across Gaza, functioning hospital capacity had collapsed to a fraction of pre-war levels, with only a small number of facilities partially operational in the south.
The people on dialysis, the children awaiting cardiac referrals, the women in chemotherapy — they did not disappear when the crossings closed and the generators stopped. They remained, inside a system that international humanitarian law requires all parties to protect, and which was — by every documented measure — failing them long before the bombs fell, and failing them catastrophically after.
Sources
- World Health Organization (WHO) — Health Cluster Bulletins and Patient Referral Reports, Gaza, 2021–2023, WHO Eastern Mediterranean Regional Office
- OCHA oPt — Humanitarian Situation Reports (Bi-weekly), 2021–2023, ochaopt.org
- UNRWA — Health Department Annual Reports, 2021–2022, unrwa.org
- Gisha — Legal Center for Freedom of Movement, reports on patient permits and crossing restrictions, gisha.org
- B’Tselem — Reports on Gaza blockade and dual-use goods restrictions, btselem.org
- OCHA oPt — “Fragmented Lives: Humanitarian Overview 2022,” ochaopt.org
- WHO Director-General Tedros Adhanom Ghebreyesus — public statements on Al-Shifa Hospital, April 2024
