The death toll continues to rise after airstrikes hit a Syrian hospital supported by the charity Doctors Without Borders/Médecins Sans Frontières (MSF) on Monday.

At least 11 people are confirmed dead at the hospital in Ma’arat Al Numan, in the Idlib province of northern Syria, according to a new statement released by MSF on Tuesday. The organizations says the 30-bed hospital was hit by four missiles in two back-to-back attacks on the facility, and they expect the death toll will rise. Rescue workers are still digging through the remains of the now-destroyed hospital. Three people were pulled out of the rubble alive.

Before and after images of the hospital, give a sense of the complete destruction of the facility.

Five staff members were killed, and two are still missing. Five patients, including one child, and a caregiver of one of the patients were also killed in the attack.

The Ma’arat Al Numan hospital destroyed on Monday had already been moved and rebuilt on more than once because of earlier attacks and insecurity. But because of increasing insecurity and the dangers to both staff and patients, MSF is unsure it will be able to relocate again.

“We do not know if the facility will reopen in another location,” said Massimiliano Rebaudengo, MSF head of mission for Syria.

The hospital had 54 staff on its payroll, two operating theaters, an outpatient department and an emergency room. MSF estimates that around 1,500 people were treated every month in the outpatient clinic; the ER carried out around 1,100 consultations monthly, and conducted 140 operations a month.

MSF has covered all of the costs of operating the hospital since September 2015, one of more than 150 clinics and hospitals to which it provides aid. The destruction of this particular hospital could have a profound effect in the region.

“The destruction of the hospital leaves the local population of around 40,000 people without access to medical services in an active zone of conflict,” Rebaudengo said.

The Britain-based Syrian Observatory for Human Rights had said Russian warplanes targeted the hospital in Idlib province, a claim that Russia denies.

In Moscow, President Vladimir Putin’s spokesman Dmitry Peskov told reporters the hospital report was another case in which those who make accusations against Russia cannot back them up.

Peskov, in a conference call with journalists, said those who make such accusations should instead do as Moscow does and rely on the “primary source” — official announcements from the Syrian government. When pressed, he told journalists the Syrian government had made a string of announcement on who could have been behind the bombing. He also noted that Syria’s ambassador to Russia said the hospital was destroyed by the Americans.

“We categorically reject such claims, even more so because each time those who make such claims prove unable somehow to corroborate their unsubstantiated accusations,” Peskov said.

Local authorities have yet to confirm who was behind the attack. But MSF believes the hospital was specifically targeted because of the work being done there.

“The destruction of the MSF-supported facility appears to be a deliberate attack on a health structure,” said Rebaudengo.

It is not the first time this particular facility has been targeted, or the first time that MSF has experienced tragedy this year alone. Since the beginning of 2016, five MSF-supported hospitals around the world have been bombed and 14 staff members killed. In 2015, the charity organization demanded answers after one of its facilities in Afghanistan was destroyed in a U.S. airstrike.

Additional information from the Associated Press.

Have something to add to this story? Share it in the comments.