Pay first, treat later: upfront payment requirements as a non-clinical barrier to timely emergency care in fragile and resource-constrained health systems.

Timely access to emergency care is essential for preventing avoidable illness, disability, and death. Yet in many low- and middle-income countries, patients and families may still be asked to make consultation fees, registration payments, deposits, or other forms of financial clearance before urgent evaluation or treatment proceeds. Using Somalia as an illustrative case while drawing broader lessons for comparable settings, this commentary examines how weak public financing, limited financial risk protection, facility dependence on user fees, and administrative payment processes may delay emergency assessment, stabilization, diagnostics, referral, and admission. It argues that payment-related delay should be understood as a health-system, governance, and equity problem rather than only a household financing problem. Because direct Somali bedside measurement remains limited, the paper frames this pathway as a policy-relevant systems hypothesis rather than a directly quantified patient-level effect. It concludes by proposing a practical reform agenda centered on triage-first and stabilize-first policies, feasible emergency waiver and reimbursement mechanisms, separation of billing from urgent clinical triage, phased financing reforms, and stronger regulation of payment practices that interfere with time-critical care in Somalia and comparable fragile settings.