In an ambulance, every second counts.

A patient's chances of survival depend on how long it takes an ambulance to respond to a case and transfer the person to the appropriate hospital. In most communities around the world, eight minutes is the recommended response time for urgent cases.

But in Palestine, not even ambulances have freedom of movement. Palestinian ambulances can be stopped at every checkpoint, the vehicle searched and emergency responders interrogated. According to data provided by Palestinian Red Crescent Society (PRCS), checkpoints delay ambulances by an average of 15 minutes.

This does not include the time an ambulance spends in traffic leading up to the checkpoints. There is only one lane leading to and from each checkpoint, causing a bottleneck traffic jam that gets especially bad during rush hours.

PRCS ambulances respond to both emergency and transfer cases. In emergency cases, patients can only go to the hospitals in their area of residence, whether it be in the West Bank, Gaza or East Jerusalem.

If the patient requires further treatment not available in their area, they then have to submit a request to Israeli authorities for a transfer.

Every year, thousands of patients from the West Bank or Gaza request transfers to hospitals in occupied East Jerusalem where six Palestinian hospitals have medical specialities not available in the West Bank or Gaza. This includes cardiac surgery, paediatric dialysis and oncology care.

In order to cross checkpoints from the West Bank or Gaza into occupied East Jerusalem, each patient needs to get a security clearance from Israel.

That permit process itself can take weeks, sometimes months, causing the patient to miss their hospital appointment. There are no clear criteria of who is eligible. When a patient gets rejected, often there is no reason given.

In 2016, 217,015 patients from the West Bank and Gaza applied for transfer (WHO). Twenty-two percent were delayed or denied transfer. The World Health Organization (WHO) called the Israeli permit process "neither transparent nor timely".

Even after obtaining the permit, transferring Palestinian patients requires careful coordination by the PRCS offices. The patients are only notified the day before that their transfer requests were approved.

It takes 90 minutes or more to coordinate the ambulance trip with Israeli authorities (WHO Access Report). Even with prior coordination, ambulances may get held up at the whim of the soldiers who are manning that checkpoint.

This delay can be life-threatening.

In order to cut down on potential delays, PRCS invented the "back-to-back" method. Instead of direct transfers with Palestinian ambulances that may be rejected at the checkpoints, a Palestinian ambulance picks up the patient from the West Bank or Gaza and then meets another ambulance (one with a yellow Israeli license plate that can drive around in Jerusalem) at the checkpoint.

The patient has to be moved from the one ambulance to the other. This method, however, can endanger patients by exposing them to potential contamination.

Israel, as the occupying power, is responsible for the health and welfare of the Palestinian population according to international humanitarian law. Access to healthcare for Palestinians is a human rights issue. But Israel often presents it as a security issue.