Informal payments and the illusion of free care: a perspective from Somalia’s fragile health system

Abstract

Universal Health Coverage (UHC) promises access to care without financial hardship, yet in many low- and middle-income settings this ideal is undermined by pervasive informal payments. This perspective introduces the concept of the "illusion of free care" to explain how official fee-exemption policies coexist with hidden, off-the-record charges that reshape access and equity. Drawing on Somalia as a critical case of health system fragility, we argue that informal payments are not isolated acts of corruption but predictable responses to chronic underfunding, weak governance, and workforce precarity. We conceptualize this dynamic as a four-stage process linking policy promises, systemic constraints, the normalization of informal payments, and inequitable patient outcomes. These practices disproportionately exclude the poorest, erode trust, and stratify care along socioeconomic and gender lines. Conventional policy responses, including anti-corruption measures and nominally free care policies, fail to address underlying structural drivers. Achieving equitable UHC requires shifting from rhetorical commitments to systemic reforms in financing, workforce protection, and accountability.