BEIRUT -- Syrian government forces and insurgents exchanged a barrage of rockets on Sunday in the country's northwest that killed at least 13 people and hit a government-run hospital, activists and government media reported.
The violence strained a fragile months-old truce negotiated between Russia and Turkey that averted a government offensive on Idlib and surrounding areas, the last major rebel stronghold in the country. The region is home to some 3 million people, including many displaced from other battles in the civil war.
The head of the local hospital in government-held Massyaf said insurgent shelling killed a rescue worker and four other people. Maher Younis told the state-run Ikhbariya TV that five children who were arriving at the hospital and two dentists were wounded.
One of the wounded told Ikhbariya from her hospital bed that the missile landed when she and her mother were arriving to do some medical tests.
"We only felt a big bang. I was wounded in my hand and my mom in her leg," she said, without giving her name.
Hospitals and civilian infrastructure have frequently come under fire over the course of the eight-year civil war, and rights groups say government forces have targeted medical facilities on several occasions. The government denies targeting such facilities and says the rebels use them for military purposes. The rebels do not have precision missiles, and mainly rely on homemade or outdated arms.
The insurgent fire came amid heightened tensions following days of government fire on villages and towns on the edge of the enclave.
Opposition-allied first responders known as the White Helmets said government shelling killed at least eight people, including one child, in Saraqeb and Nairab towns in eastern Idlib. The Syrian Observatory for Human Rights put the death toll at nine. The activist-run Shaam news agency said the shelling in Saraqeb hit civilians who were visiting a local government office.
On Thursday, the U.N. said there has been an "alarming spike in civilian casualties and new displacement," with increased fighting and intensification of airstrikes in the truce area. It said in March alone, 90 civilians were reportedly killed, nearly half of them children, and over 86,500 people were displaced in February and March, compounding an already precarious humanitarian situation on the ground.
Russia, which backs President Bashar Assad, and Turkey, which supports opposition factions, reached the truce deal in September. It set up a demilitarized zone on the edge of the rebel-held enclave which was to be cleared of militants.
But since the deal, al-Qaida-linked militants have expanded their presence in the enclave, seizing land from other armed groups.
The government so far has kept up limited military pressure. Experts say government forces are focused on opening key highways that pass through Idlib, linking northern Syria to the capital, Damascus. Opening the highways was one of the key provisions in the September deal.
Separately on Sunday, Russian Foreign Minister Sergey Lavrov called for the dismantling of a remote camp for displaced people along the Syria-Jordan border.
"We support the (Rukban) camp to be dismantled as soon as possible," Lavrov said.
Rukban has a population of over 40,000, whom the U.N. says are stranded in dire conditions. The last aid delivered there was two months ago. U.N. officials say most of the camp's residents want to leave but fear for their security and need more safety guarantees.
The camp lies near a U.S. military base and within a de-confliction zone set up between Washington and Moscow. Russia has accused the U.S. of denying humanitarian access to the camp, allegations denied by the U.S.
Hedinn Halldorsson, a spokesman for the U.N. Office for the Coordination of Humanitarian Affairs, said the U.N. is "in discussions and facilitating dialogue with and between all relevant parties," adding that "the U.S. military has not presented any obstacles in terms of access or aid to Rukban."
At least 400 Rukban residents left Sunday toward shelters provided by the government in the central Homs province. A total of 1,660 have left since March 24, Halldorsson said.
Associated Press writer Albert Aji in Damascus, Syria contributed to this report.