Idlib, Syria – Ayman al-Khayal, 43, sat with his family as he waited for his latest dialysis session at Bab al-Hawa Hospital in the north of Syria’s Idlib province.

He was looking forward to having a few hours of rest as the treatment proceeded, doing the job of removing toxins from his body that his kidneys can no longer do.

Al-Khayal has been receiving free dialysis three times a week for the last nine years at Bab al-Hawa Hospital, located near the Bab al-Hawa border crossing with Turkey.

But that vital service may soon no longer be available for him or the facility’s other 32,000 monthly patients, as the hospital faces an existential funding crisis.

Funding crisis

Over the last year, Idlib’s medical services have been severely underfunded and now Bab al-Hawa Hospital is at risk of closing by the end of September, threatening the healthcare provided to hundreds of thousands of patients.

“If the support doesn’t continue, the only place that will receive me is the cemetery,” al-Khayal told Al Jazeera with a wry smile.

His nine-year-old daughter Madiha was sitting beside him. She shook her head stubbornly and said, “We’ll find you another hospital.”

After the Syrian uprising of 2011 was violently suppressed by President Bashar al-Assad, the country has fragmented into zones of control, with Idlib dominated now by the armed group Hay’et Tahrir al-Sham al-Sham, a group whose leader was formerly affiliated with al-Qaeda.

Now, after 13 years of war, many Syrians face uncertain economic, security and even medical outcomes.

This issue is particularly acute in opposition-controlled areas of Syria such as Idlib, where a severe lack of funding has forced dozens of medical centres and hospitals to close in the past year.

The health facilities still open have struggled to provide care for the increased number of patients needing their services. But the closure of a large hospital like Bab al-Hawa is expected to lead to a medical crisis, with the remaining healthcare facilities unable to serve all those in need.

The number of patients with kidney failure, for example, is estimated to be in the hundreds in Idlib, an area with more than 3 million residents, the majority of them internally displaced, according to the UN Office for the Coordination of Humanitarian Affairs.

There are so few centres with dialysis machines that patients are forced to wait for other patients to transfer or even die so they can have the opportunity to receive free treatment themselves.

For people like that, Bab al-Hawa is a literal lifesaver. The hospital treats 32 patients with kidney failure daily and is the only free facility that provides microscopic brain surgery and paediatric surgery among other specialities.

And each month, 1,200 surgeries are conducted and 150 patients receive cancer treatment, further highlighting how vital the hospital is.

But funding for Bab al-Hawa expires at the end of September, according to the Syrian American Medical Society (SAMS), which has run the hospital since 2020. Efforts to find new donors have so far failed.

“The lack of funding is not limited to Bab al-Hawa and is not the decision of one donor, but there are different interests for the donors and a common reluctance to cover medical facilities,” SAMS said in a statement.

Since the beginning of 2024, health authorities in Idlib have been sounding the alarm about closing hospitals and health centres due to lack of funding and the suspension of humanitarian projects in the region.

“The funding has declined over the past year by about 35 to 40 percent,” said Muhammad Ghazal, head of primary care and the development and modernisation division at the Idlib Health Directorate.

Ghazal believes that donors’ preoccupation with other humanitarian catastrophes around the world, such as Gaza and Ukraine, is the main reason for the decline in support.

Syria, once the focus of global attention at the height of its war and the subsequent refugee crisis, has slipped out of the headlines, leaving organisations struggling to help the millions still in need, particularly in areas not controlled by the government.

On the edge of collapse

Kidney failure patients greet each other as they enter their designated rooms in Bab al-Hawa.

As al-Khayal sat on his bed and prepared for his treatment, he estimated that there were eight kilogrammes (more than 17.5 pounds) of fluid in his body, which will gradually be removed over the next four hours by the dialysis machine.

Al-Khayal’s kidney failure was the result of a shooting incident in 2008. At that time, he lost a kidney and his spinal cord was injured, paralysing him from the waist down.

In 2015, his other kidney stopped working due to infections.

“My wife, Samia, was a bride when I was paralysed but she did not abandon me,” al-Khayal said with a smile as he described the support of his family, including his wife, daughter, and 16-year-old son Mohammed, who left school this year and is training to become a carpenter to help out the family.

Al-Khayal says he is unable to work and depends on the $100 monthly stipend his 82-year-old father gives him.

He does not blink as the doctor connects the dialysis machine tubes to his swollen arm, but sighs as he talks about what his treatment costs will be when the hospital closes.

“A single dialysis session in a private hospital costs $40, in addition to the medications I will need,” he said. “Even if I went to another free hospital, I can’t afford the transportation.”

Al-Khayal lives a few kilometres away from Bab al-Hawa, in Sarmada, and is given free transportation to the hospital. To reach the next nearest treatment centre, he estimated that he would have to pay more than $350 a month.

Bab al-Hawa, which was established in 2013, is centrally located, making it a convenient outpost to serve about 1.7 million people.

The hospital has had two funding cuts before, but managed to keep running with a fifth of the funding it actually needs, according to Dr Mohammed Hamra, its director.

“Each time [funding was cut], we reduced the number of staff and increased the pressure on employees to continue providing the same services to patients,” Hamra said.

“The cessation of support for the hospital does not mean it will close, but it will stop providing unique services.”

Hamra does not plan on simply letting the hospital close. He is preparing a plan for volunteer work that includes a staff of 70 specialists, 160 nurses, and 140 administrators. However volunteering is not a viable long-term solution to the funding crisis in the region, where the majority of the population suffers from poverty. Employees need an income to secure their livelihood and medical supplies are expensive.

David Carden, UN deputy regional humanitarian coordinator for the Syria crisis, told Al Jazeera that the health situation in northwest Syria “is teetering on the edge of collapse”.

He said a third of the 640 health facilities are currently non-functional due to the effects of the Syrian conflict.

At the current rate of funding shortages, as many as 230 health facilities, or half of all functional health facilities in northwest Syria, will face full or partial closures by December.

By the end of August, 78 health facilities, including 27 hospitals, had already fully or partially suspended operations in northwest Syria due to underfunding.

Slow solutions

A lack of funding is not the only reason for the pressure on the health sector. The earthquake disaster at the beginning of 2023 and the spread of epidemics – such as COVID-19 and cholera – has also played a significant role.

The economic pressure is mostly felt by patients, as Ghazal, from the Idlib Health Directorate, estimates that 90 percent of them are unable to afford private sector services, while free treatment centres are decreasing.

“Stopping support means stopping the service, which means increasing the rate of diseases,” he said.

Ghazal did identify a few alternatives to address the decline of healthcare, like redistributing health services in the region, merging facilities, finding new donors – such as Gulf states that have begun to support medical projects and charities – and charging patients small fees to help the hospitals and health centres procure supplies.

Al-Khayal, however, fears any solutions may not be sufficient to get him the treatment he needs.

The end of September is approaching quickly and he fears the worst if officials do not find a solution quickly.

Madiha looked up from her notebook and smiled as she promised to complete her studies. She wants to become a doctor.

Al-Khayal smiled back at his daughter, but couldn’t hide his anxiety.

“The more we delay the dialysis, the more the pain and toxins increase in our bodies,” he said.

“We wouldn’t be able to survive if we don’t get treatment for even four or five days.”