Warplanes of a Saudi-led coalition struck a hospital in northwestern Yemen on Monday, the medical charity Doctors Without Borders and officials said, leaving at least 11 people dead in what is seen as another blow to an already battered health system.
Doctors Without Borders confirmed on its official Twitter account that airstrikes had hit the hospital in Abs, in the rebel-controlled province of Hajjeh, the fourth attack in nine months on a facility supported by the charity.
The organization, which is also known by its French name, Medecins Sans Frontieres (MSF), issued a statement late Monday saying that 19 people had been injured in addition to the 11 dead.
"Once again, today we witness the tragic consequences of the bombing of a hospital," said a statement from Teresa Sancristóval, desk manager for the charity's emergency unit in Yemen. "Once again, a fully functional hospital full of patients and MSF national and international staff members was bombed in a war that has shown no respect for medical facilities or patients."
The Houthi rebel movement, which is nominally running the government of Yemen, has been locked in battle with a coalition of Arab states led by Saudi Arabia for the last year and a half. The coalition is fighting to reinstate Yemeni President Abdu Rabu Mansour Hadi, who fled to the southern port city of Aden early last year and whose government operates in exile.
Doctors Without Borders said that it had been supporting the hospital since July 2015, treating 4,611 patients in that time.
A local humanitarian staff member, who did not give his name because he was not authorized to speak to the news media, said the bombardment had struck the triage area near the hospital's emergency room, where patients would line up for screening.
"There were no armed people there," he said.
He added that the hospital, like all facilities supported by Doctors Without Borders in Yemen, was marked with the group's red and white flag to avoid being targeted by warplanes.
There was no immediate comment from Saudi authorities.
Images uploaded by activists on social media showed the strike's aftermath. Shrapnel had slashed the cement columns of the hospital's waiting area. The burning husk of a taxi, said to have been bringing patients, was overturned by the force of the blast.
The attack came two days after another airstrike on what Doctors Without Borders said was a school in the town of Haydan, in neighboring Saada province, killed 10 children between the ages of 8 and 15.
The coalition, however, argued that the bombing had targeted a training camp for child soldiers -- a routine disclaimer by Saudi authorities who insist that the Houthis, who hold sway over large swaths of northern Yemen, use civilian structures to house their fighters.
"There is no school in this area," Maj. Gen. Ahmed Asseri said during a news conference in Riyadh on Sunday, according to Agence France-Presse. He also criticized Doctors Without Borders, saying it should "take measures to stop the recruitment of children to fight in wars instead of crying over them in the media."
Aid officials spoke of a jump in violence in recent days, after peace talks in Kuwait failed to yield a result.
Saturday's strike added to "an intensity of airstrikes having an impact on civilians we haven't seen so far," said UNICEF Yemen representative Julien Harneis.
In a Skype interview on Monday, Harneis described a health system on the brink of collapse. He said patients live in fear of being bombed inside medical facilities already buckling under the pressure of a collapsing economy.
"There were children who survived the attack in Haydan but they decided to not go to the hospital in Abs because they were afraid of using any health facilities in the north," Harneis said. Instead, they went to Sana, the Yemeni capital, an almost 100-mile detour.
But even those reaching a hospital in time have no guarantee it will be functional.
With Yemen under an embargo, medical facilities are not able to replenish their supplies. Activists speak of people being forced to use expired medications.
Those seeking medical assistance abroad cannot leave from Sana, where the coalition has closed the airspace to civilian flights, although it said it would allow humanitarian flights to resume on Monday, according to a report by Saudi news operator Al Arabiya on Sunday. It was not clear whether those flights did resume.
Harneis said the country's failing financial system, however, has added another obstacle: A lack of liquidity coupled with an inability to access foreign currency has left caregivers as well as aid administrators unable to pay for desperately needed services.
"You cannot get cash out of the bank, [people] can't take the money we pay them," Harneis said, explaining that rials, the country's currency, are printed abroad and flown in.
"And the government just announced they can no longer pay operational costs for hospitals, so they don't have money to pay for transportation and fuel," he said.
The victims hardest hit by the health-system crisis have been children.
The U.N. has accused the Saudi-led coalition of killing or maiming 60% of the 1,953 casualties among children in 2015.
In June, U.N. Secretary-General Ban Ki-moon said he was pressured to remove the coalition from a blacklist of violators of children's rights in armed conflict, a charge Saudi Arabia has vehemently denied.
But for Sana-based analyst Hisham Omeisy, the strike on the Abs hospital hinted at a "growing confidence of being above international law" since the Saudi-led coalition succeeded in overturning the U.N.'s decision to place it on the blacklist.
"Such enhanced impunity," he wrote in an interview on social media Monday, "where the coalition assumes greater leeway in acting with utter disregard to civilian casualties, can and already has spelled disaster to the many helpless people of Yemen caught in the crossfire of the current war."
Bulos is a special correspondent.
2:35 p.m.: Updated with staff member saying hospital was marked with a flag.
1:25 p.m.: This article has been updated throughout with staff reporting and an adjusted casualty toll.