Introduction

The health sector has always been considered an area vulnerable to corruption both administrative (petty) and high (grand) with a serious negative impact on public health systems (European Commission 2017, Vian 2008). This is due to a host of interrelated factors, such as the vulnerability of patients, the size of the financial flows around the health sector and the potential for private profit, the increasing competition between companies, the inadequate regulatory framework, the poor monitoring and weak control. (Radu 2016). Most notably, the stakeholder ecosystem that makes up the health care system is characterised by intricate complexity, including a multi-layered mix of public and private providers and actors (Transparency International 2017; Holmberg and Rothstein, 2011) and a large size of relevant industries and their financial flows (for example, the biomedical, pharmaceutical, and medical service industries). As public spending for health continues to be one of the larger allocations in many countries (Savedoff, 2006) and the private sector competition leads to large-scale investments, the environment in which these actors are operating is ripe for the development of corruption and illegal practices including bribery, extortion, kickbacks for public contracts, direct or indirect benefits for cultivating a favorable environment, manipulation of procurement procedure, supplier induced demand, trade of influence, lobbying, guided legislation and policy capture. (Radu 2016; Taryn 2008; Transparency International 2017). These phenomena cause multi-level social harms as they have a serious negative impact on public health status, health services and social welfare systems, while at the same time causing financial leakages and wastage of public funds that could be allocated to social policies (Vian 2008).

However, although the above opening thoughts are readily repeated in official reports and public discourse, there is little criminological research that addresses the analysis of the phenomenon, such as the Braithwaite’s classic study in the 1980s, which captures the illegal practices of the pharmaceutical industry in the light of corporate crime and the layered social harms created in this context (Braithwaite 1984). On the other hand, the focus on informal payments by patients to doctors and public health providers is often used as a smokescreen to cover up the more serious forms of corruption that take place, mainly in the field of procurement with the cooperation or tolerance of state actors (Gasparinatou et al. 2022). This study aims to address this research gap, to explore the phenomenology of high-level corruption in the health sector beyond individualistic interpretations, to highlight the relational, organizational and organized nature of the phenomenon, to reveal its interconnections and links, and ultimately to show how corruption practices are normalized, embedded and assimilated into the grid of state function through complex practices and processes.

In Greece, the health sector is consistently listed as a high-risk sector for corruption and illegal practices. This is also reflected in the national strategic plan for the fight against corruption, which includes the health sector as one of the most vulnerable sectors to corruption along with the tax and customs administration, local government and the defence sector (National Anti-Corruption Action Plan 2018–2021). The public’s perception of both the extent of corruption in general and the severity of the problem in the health sector is similar. With respect to the Eurobarometer on citizens’ perceptions towards corruption (Special Eurobarometer 523, 2022), 98% of respondents believe that corruption is a widespread problem in the country (the highest level in among EU countries). Accordingly, 91% of the Greek respondents believe that bribery and abuse of power for personal gain are widespread in the health system (compared to 81% in 2019, + 10pp) while the average perception of corruption in the health system in other EU countries is 29%.

Furthermore, according to an official parliament report (Hellenic Parliament 2018) corruption in the health sector and the huge costs associated with the supply of medical devices and medicine were even considered as one of the main causes of the Greek financial crisis (2009–2019). A comparison of the annual growth of pharmaceutical expenditure in real per capita terms for the years 2000–2009 between Greece and the rest of the OECD countries highlights the size of the problem, since other OECD countries experienced an average growth rate of 3.5% while Greece had an increase of 11.1% (OECD, 2011). In 2009 pharmaceutical expenditure reached 5.1 billion euros while the total health expenditure in the same year amounted to 23.2 billion euros (OECD 2011). Despite the huge financial drains mainly in relation to the procurement system, only few studies have investigated corruption in health. These focus mainly on informal payments made by patients (e.g., to expedite surgeries, to facilitate access .) (Liaropoulos et al. 2008; Souliotis et al. 2015; Giannouchos et al. 2021), rather than on the phenomena of high corruption, the networks and processes that underpin them and respectively the relations among companies, doctors and state actors.

In the years following the outbreak of the economic crisis, grand corruption practices in the health sector in Greece were subject to judicial and parliamentary investigation (see in detail Hellenic Parliament 2018), and these investigations focused mainly on: a) the operation of a Greek Hospital named “ERRIKOS DYNAN, b) the compensations for diagnostic arthroscopies c) the pharmaceutical policy and drug supplies during the years 1997–2004, d) the operation of “KEELPNO”, a legal entity under public law, supervised by the Ministry of Health, which functioned as a vehicle for clientelism, corruption and patronage e) some big cases with international impact and the involvement of a large number of actors such as DePuy case, a subsidiary of Johnson & Johnson, supplier of orthopedic medical devices and Novartis Case a well-known multinational pharmaceutical company (USA v. DePuy Inc. Crim. 11-cr-00099-JDB 2011; R. v. Dougal [2010], EWCA Crim. 1048; United States v. Novartis Hellas S.A.C.I, 20-cr-00538 (D. NJ June 25, 2020). In the first case (DePuy) the USA court decision refers to improper payments to Greek Health Care Providers and Greek Agents totaling approximately $16.4 million. In the second case (Novartis) according to press releases and estimates by the audit and prosecution authorities, the kickbacks estimated at EUR 50 million while the total loss to the state for the period 2000–2015 reached 3 billion euros for the same period, the public loss from the illegal practices of all pharmaceutical companies is estimated at €23 billion (Dima 2018; Naftemporiki 2018). However, the disclosure of corruption scandals in health sector, their investigation as well as their presentation in the press and public discourse have been ambiguous and controversial.

That the present state of knowledge and public awareness nowhere reflects the complexity and the gravity of the issue can be further illustrated by the latter Novartis case. In 2016, an investigation was launched by the FBI in the US, when two former employees of the subsidiary Novartis Hellas were placed under whistleblowing protection. They reported the company’s illegal practices of unfair competition through bribes and indirect benefits to doctors and officials in Greece in order to increase sales in the prescription of certain drugs (USA Vs Novartis Hellas, Crim. No. 20–538). The whistleblowers also revealed the mechanism that the company had set up to gain a dominant position in the Greek market with the assistance of the media, the healthcare community and political actors, as well as the company’s influence on the pricing and reimbursement procedures of the drugs, in which it was given favorable treatment (OECD 2022; GRECO 2022). The US investigation included the false records of bribes in the Novartis AG’s books, financial records and accounts as legitimate advertising and promotion expenses and then the false financial profile of the company before SEC and investors (USA v. Novartis Hellas; SEC Release no. 89,149 / June 25, 2020), illustrating the symbiotic relationship between corruption and financial crime (Roth and Kauzlarich 2016; Vidali 2017).

In Greece the investigation of the case opened in 2017 when the whistleblowers testified before the Greek anticorruption prosecutors. The preliminary judicial investigation included not only health care providers and company’s executives but also ten high-ranking political persons including two ex-prime ministers and eight former ministers (Marks 2018). The case also triggered a high-profile parliamentary inquiry. Still, over a four-year period, the judicial inquiry and the politics surrounding the case led to development which arguably fail to address the core of the phenomenon. These were (a) the prosecution of the company’s CEO for passive bribery and money laundering through advertising companies (dikastiko 2022); (b) the prosecution of a former health minister; (c) the archiving of the investigation for all other political persons, although in 2 cases of former health ministers, amounts of unclear origin were found in bank accounts(Financial Crime Prosecutor, filing act 3752/24.01.2022; iEidiseis 2022; Triantis 2022 ); (d) the prosecution of the former Minister of Transparency and Human Rights with charges of criminal organization, abuse of power, breach of duty, extortion and other crimes (Kathimerini 2020); (e) the abolition of the Anticorruption Prosecutor and its merger with the Financial Crime Prosecutor’s Office (law 4745/2020); (f) the prosecution of the anti-corruption prosecutor who handled the case for misuse of power, breach of duty, false declaration, breach of official duty and breach of personal data (Mandrou 2020) (g) the prosecution of two investigative journalists who covered the case for membership in a criminal organization and three counts of conspiracy-to expose innocent people to prosecution, to extort, and to breach duty (Reporters without Borders 2022). It is characteristic that all the above charges and prosecutions collapsed and were archived after the respective acquittals by the judicial councils for various reasons such as lack of evidence, non-establishment of the offence or for reasons of statute of limitations.

it is worth noting that in June 2020, Novartis reached a settlement totaling $347 million with the US Department of Justice (DOJ) and the Securities and Exchange Commission (SEC) for violations of the Foreign Corrupt Practices Act admitting illegal payments to Greek officials and healthcare providers (United States District court, Criminal No. 20–538, SEC Release no. 89,149 / June 25, 2020). Following this and with considerable delay the Greek Government filed a lawsuit in June 2022 to hold Novartis accountable for bribery of health care providers (Kathimerini Newspaper, 17.06.2022). The public views for Novartis case are also controversial and under intense political debate. The current conservative government, some parliamentary parties and part of media consider the issue to be a conspiracy against the right wing and the ex-social democrats’ political exponents (Chrysopoulos 2019). The leftist parliamentary opposition party, and some media consider a typical case of state corporate crime involving political and other forms of corruption, violation of medicines prices, guided legislation and others forms of policy capture (Psarra 2021).

The Novartis case illustrates the structural nature of corruption, pointing to issues associated with the power relations, the differentiated procedures of the law towards persons with status and power, (Sutherland 1940, 1944; Tombs and Whyte 2003a, 2003b) and the broader context of crimes of the powerful (Pearce 1976; Barak 2015). Clearly such phenomena have been incubated and reproduced for decades in the structures of the state and are by no means sporadic or connected only with the deviant behaviour of certain officials. Rather they invite consideration of the structures, relations and processes which constitute the health sector and its relations with the underpinning economic and overarching political systems (Merton 1968; Chambliss 1988).

The present study undertakes this task by analysing the procedures, practices, and methods of high corruption in the health sector and especially in the procurement system. We distinguish clearly between petty corruption, described as the abuse of power by low or mid-level public officials occurring during their personal contact and interaction with citizens, in their access to goods or services; and grand corruption, involving acts committed by top public and private sector officials which undermines democracy and social prosperity (Della Porta 2002; Transparency International 2009). Our argument is that these cases are not occasional or isolated but phenomena of a systemic-structural nature, which are developed either in the spectrum of illegality or in the grey areas of legality. At the same time, they are consolidated in the institutions and the grid of the legitimate state function (Chambliss 2004).

In the following sections we present the theoretical framework, the key research questions and the research methodology, followed by the presentation and analysis of our findings with a focus on the structure of corrupt networks, the processes of normalization within organizational frameworks and the interdependencies with other phenomena.

Theoretical considerations

Corruption is a sociological term reflecting a social phenomenon, under which various behaviours, acts, omissions and social practices are grouped, which are either formalised in criminal law as legal offences or do not constitute formal crimes, but rather broader phenomena affecting administrative and democratic function. Most of them have a relational nature, involving a wide range of activities and actors (Diviák et al. 2019) within organizational and professional frameworks (Ashforth and Vikas 2003). In all cases, at the core of corruption is the abuse of entrusted power (public or private) in order to obtain private (individual or organisational) benefit (Transparency International 2009).

Moving beyond conceptualization of corruption as individual deviancy, the systemic nature of the phenomenon is arguably more accurately captured by a state-corporate crime perspective. Kramer and et al. (2002) have argued that many crimes, especially in the field of white collar and crimes of the powerful, arise through the interrelation and interdependence between private/business actors and public/state governance actors, through the coincidence and promotion of common goals and objectives (see also Michalowski and Kramer 2007; Roth and Kauzlarich 2016, Tombs 2012). This “mutually reinforcing interaction of policies and practices” (Aulette and Michalowski 1993: 175) between economic institutions (corporations) and state institutions (government and public administration) may take two distinct forms, which often alternate and interact (Barak 2015). In the first case, the state has an active role and promotes, attracts, or initiates cases of organisational deviance. The crimes committed are therefore directed or discretely approved by state actors (state initiated corporate crime) (Kramer 1992; Kauzlarich and Kramer 1993). In the latter, the state governance bodies have a passive role, failing to control, restrain and suppress illegal acts or omissions. In this case, state actors systematically fail or neglect to set limits on business activity, thus facilitating illegal or socially harmful acts and omissions (state-facilitated corporate crime) (Aulete and Michalowski 1993; Matthews and Kauzlarich 2000). This type includes both the lack of an adequate regulatory framework and legislation as well as the inability or ineffectiveness of law enforcement authorities to enforce existing rules (Michalowski and Kramer 2007).

It follows that corruption is not the outcome of one or more deviant behaviours of certain public and private sector officials, but rather the product of the relationship between different social institutions (Kramer et al. 2002; Michalowski and Kramer 2007: 209). Rather the investigative focus falls on the interactive horizontal and vertical relations that are developed between economic and political institutions and between different levels of organizational action (Michalowski and Kramer 2007), and more specifically at the three interdependent levels of the individual, the organisational/institutional and the political-economic (Kramer et al. 2002). In this context, the structure of economic and political arrangements in each society, as well as the dominant cultural meanings of the political economy, determine and signify both organisational goals (explicit or implicit) and individual motives for social action (see Vaughan 2007).

The processes which normalise corruption (Della Porta and Vanucci 2012) emerge at the intersection of the coincidence of the objectives and interests of state governance actors at on the one hand and business actors on the other (Tombs 2012). ‘Normalisation’ denotes the social processes of rationalization, institutionalization and integration of corrupt practices in structures and organisational contexts to an extent that it is considered a common, recurring and necessary condition of social economic and political action (Ashforth and Vikas 2003; Vaughan 1999; Vikas et al. 2004; Sherman 1980): it’s about ‘the way of doing business’, ‘the way politics works’, and how ‘you either play by the rules of the game or you’re out’. Through these complex processes at the individual, organisational and structural levels in which corruption gradually loses its harmful character as a violation of rights and becomes a routine, a normal ritual (Roth and Kauzlarich 2016: 44–45, Braithwaite 1984, 1989).

At the individual level these processes focus on motivations, definitions, social meanings, perceptions of availability and attractiveness of illegal means in the context of differential association (Sutherland 1940, 1949/61). In the interactional field, moral agents learn from the “significant others” not only crime techniques, but also techniques of rationalization, justification, separation of consequences, diffusion of responsibility and generally techniques of moral neutralization (Sykes and Matza 1957; Cohen 2001). These processes focus on how a personal morality and ideology is dialectically assimilated, contributing not only to the delegitimization of rules but to the building of a new value system, so that individuals do not consider themselves as breaking rules, but instead as conforming to the normative framework of the sub-group to which they belong (Vaughan 2007).

Αt the organisational level, these processes focus on institutionalising and embedding the new practices and values in structures and organisational contexts, forming a strong organisational subculture and normality - i.e. recurrent cultural and professional practices, which may include processes of reward or disapproval, silence, concealment, silent encouragement, implicit understanding, impunity, forgetting, obfuscation, but also organisational goals, cultural and value assumptions, projected norms, aspirations, and claims,. that dialectically build a secondary but powerful normative system within the organisational context (Passas 1990; Vaughan 1982, 2007).

Finally, the structural level includes the issues of control, monitoring and accountability. In this perspective, the weaknesses of social control, the longstanding inability or unwillingness of state governance institutions to regulate and control corruption are embedded in a broader context of a persistent state-facilitated crime. The state through omission and withdrawal from the economic sphere multiplies the illegal opportunities in the name of economic accumulation, growth and profit (Michalowski and Kramer 2007). At the structural level, the processes of normalization of corruption are being addressed in the economic and political structures of capitalism (Quinney 1977; Young 1981; Barnett 1981), in the strain conditions caused by the gap between cultural goals and the available legal means (Merton 1968). This approach focuses on the political economy of corruption, explaining how corruption through latent functions acts as a backup to the system (Gasparinatou 2021), filling its institutional gaps and structural contradictions. (Chambliss 1993; Lasslett 2013).

In this perspective Kramer and Michalowski (2002) propose an integrated theoretical model, in which the three different levels of analysis, the differential association (micro-level), the organizational deviance (meso-level) and the political economy (macro-level) perspectives do not operate in a tight and isolated way but in combination with reference to three interdependent and mutually reinforcing catalysts: (a) individual motivation or performance pressure, (b) the structure of opportunities in organizational contexts and (c) the operationality of control. From this point of view, the economic and political arrangements in a social formation, the cultural meanings, the value framework of the existing political economy, shape the goals and means of economic and political organizations as well as the roles and functions of work positions both in public and private organizations (Michalowski and Kramer 2007). Individuals are required to adapt to specific roles, expectations and functions that derive from these positions. On the other hand, within closed organisational contexts and through differential social association, individual motivation is shaped, any inhibitions and different meanings are broken down, individual experience and ultimately symbolic reality is constructed. Extending this reasoning, it follows that criminal or deviant behaviour arises when pressure to achieve goals, the availability and attractiveness of illegal means, lawlessness and the absence of effective control coincide and interact. In other words, it is the political economy that gives content and meaning to corporate subculture, organizational and individual action, and conversely, individual experience confirms conditions of anomie in organizational and structural contexts.

More specifically, the literature review and the review of reports by international organizations and national bodies (European Commission, 2017; Greece-OECD Project, 2017; Transparency International 2017, Hellenic Parliament, 2018 and annual reports of audit bodies), show that corruption in the health sector takes various forms and occurs mainly at three levels: (a) in the relations between patients and doctors (health care providers), (b) in the relations between private sector’s executives (pharmaceutical and medical representatives, companies, promoters) doctors (public or private) and pharmacists, with an impact on the prescription and referral process and (c) in the relations between business actors (representatives of medical-technology and pharmaceutical companies) and high-level public officials, who take decisions at central level, with an impact in the field of lawmaking, health policy and decision-making.

The first level is dominated by active and passive bribery in the form of informal payments to doctors by patients, to secure access to health structures, to expedite a service (e.g., securing a bed for surgery) or as additional payment for their services (Transparency International 2017; Liaropoulos et al. 2008; Souliotis et al. 2015; Giannouchos et al. 2021). Informal payments may be made as an expression of patient gratitude or take the form of extortion when they are demanded by doctors, who often cultivate a climate of insecurity and fear among patients in order to force them to pay. (European Commission 2017). There may be an implicit tolerance of these transactions by the state and citizens as a compensation for the low salaries of public doctors. From this perspective, as Green and Ward have pointed out, corruption practices could also be studied in the light of state crime theory when there is a tacit tolerance by state governance actors towards phenomena that act as a countervailing factor to the government’s inability to ensure a decent income for state officials (Green and Ward 2004).

At the second level we find a variety of corrupt practices related to the referral and prescription process of doctors on the one hand, and to the procurement process in health structures on the other (Transparency International 2017; Hudon and Garzón 2016; Vian 2008). This level includes the illegal marketing practices from private companies and the provisions of any kind of benefits as kickbacks to doctors and health professionals in order to promote and prescribe medical devices, drugs, or further medical-diagnostic examinations resulting in the phenomena of induced or artificial demand, unnecessary prescription, over-prescription, overcharging of medicine or med tech products, unnecessary medical referral, non-necessary medical-diagnostic examinations, unnecessary medication, fake prescriptions, and overpricing of technical, cleaning or safety services (Radu 2016; Transparency International 2017; European Commission 2017). Many other corrupt practices reside in the procurement system process, in the supplies of medical devices, medicines, materials (e.g. gloves, syringes, catering) and services (cleaning, storage, technical support) in health structures (European Commission 2017, Hellenic Parliament 2018).

In Greece the lack of an efficient centralized procurement system leaves room for individual tenders per hospital or health region, tailor-made call for tenders, segmentation of quantities and amounts, so the procurement rules do not apply and direct assignments (almost 80% of supplies) with opaque criteria (European Commission 2017). Moreover, it is well known the illegal practices related with specific customized products, out of procurement rules (e.g. cardiological, orthopedical products), the overcharging of companies and the artificial demand from public doctors with corresponding commissions and trade-offs (Greece-OECD Project 2017; Hellenic Parliament 2018). Corrupt practices also arise from delays in payment of health care providers, with the main form being the favourable prioritisation of payment orders in favour of certain providers. In fact, in this area, there is also an implicit tolerance by public authorities to obvious overcharging of products (drugs, medical devices) by companies, on the basis of a mutual understanding of the resulting damage to the companies from late payments, which is budgeted at the initial cost (Greece- OECD Project 2017).

At the third level (relations between businesses and high-level public officials in lawmaking, policy-making and decision-making), we mainly encounter the phenomena of policy capture, legislative capture, influence trading, lobbying, conflict of interest and revolving doors (Transparency International 2017, Radu 2016). The third area includes the partnerships of companies with political or administrative leadership, which aim to influence the medicines circulation, pricing and reimbursement process (Radu 2016; Greece-OECD Project 2017). The pressures by pharmaceutical companies on the political leadership operate in gray areas, on the borderline between legality and illegality, and include lobbying guided lawmaking practices, policy capture and shadow funding of political parties for cultivating a favourable climate (Dukes et al. 2014: 163–167). This category also includes the use of public or private legal entities (like the case of OKANA and KEELPNO in Greece), which are under the supervision of the Ministry of Health, as vehicles for clientelism, flexibility of rules in recruitment, illegal distribution of public money and direct assignments to political affiliate persons. (Greece-OECD Project 2017; Hellenic Parliament 2018)

From the above it is concluded that the first level is dominated by phenomena of petty corruption, which are manifested by low or mid-level public officials (doctors) in their personal contact and interaction with citizens (patients) (Transparency International, 2009: 33), while on the contrary, the second and third levels are dominated by phenomena of high or grand corruption. The later, are mainly linked to the procurement process with an impact on public revenue, social welfare and the democratic process (Transparency International 2009). This does not include only the Hospitals and the local health units but also, the private clinics, the diagnostic centers, laboratories, and outpatient clinics of private hospitals that provide services outside the NHS,. All these organizations along with private sector co-shape the market of medicine and medical devices by affecting the demand and the pricing. Furthermore, it is important to understand that the above levels do not operate as separate or closed systems, but interact with each other, revealing the link between small and large-scale corruption and their mutually reinforcing nature (in this perspective, see Mashali, 2012). On the one hand, the limits of tolerance towards corrupt practices at all levels of the social hierarchy are increased, as everyone benefits from the operation of the system. On the other hand, the economic flows of the individual subsystems are de facto affected and shaped by illegal or unfair practices. Thus, for instance, the preference of one particular surgery over another on the basis of an illegal transaction automatically shapes the scale of the hospital’s supply needs. The selection of surgeries to be performed also implies the ordering of specific materials that will be required.

Moreover, from the review of the judicial cases (see above the DePuy and Novartis cases) and the review of the annual reports of the administrative control bodies, emerge some important qualitative features for the analysis. Firstly, corruption in the health sector has a persistent, long-lasting and recurrent character. The cases that have been brought before the judiciary reveal a system that has operated for decades in the background and is probably still operating. The diachronic nature of the phenomenon moves us away from the exclusive criminal responsibility of individuals, opening up questions about the structural-systemic features of the phenomenon that ensured its survival and continuation. Secondly, the illegal practices of companies and doctors appear not to have been limited to certain individual cases but were instead pervasive, involving thousands of doctors, whether in the public or private sector, in their pay roll. Accordingly, it could be assumed that if a multinational company with integrated control systems resorted to illegal practices to strengthen its market position, other companies would probably resort to similar methods in order to survive in the market.

This reasoning leads naturally to the assumption that the illegal practices did not only concern specific actors, but instead arise within closed organisational frameworks and structures, in which a culture of impunity, lack of control and abuse of power is embedded and institutionalised. This approach, as mentioned, does not exclude the consideration of individual motivation, nor the organisational goals that drive individual and corporate action. Rather, it involves a comprehensive multi-level analysis by dialectically examining all three levels of social action (individual, organizational, structural), focusing on how they interact, influence and reinforce each other. From this perspective the analysis is not static or linear but moves simultaneously across many levels, in the relationships between them, the processes that underpin them, the networks that are created and operate as power subsystems, the wider environment that underpins and reproduces them and the latent functions they may have in sustaining the system in general.

In conclusion, the corporate-state crime perspective in the health sector moves the analysis beyond the individual responsibility of doctors and public officials to the structural features of the system, to the way the individual subsystems are connected, function and reinforce each other, to the social processes and relations that develop at the horizontal and vertical levels. Our research, as discussed above, focuses on social processes of normalization and institutionalization of corruption within closed organizational contexts and the mutual partnerships of private and public actors on the basis of common goals and objectives. Further, the state-corporate crime perspective broadens the analysis to the persistent, long-standing, organizational and organized nature of corruption in the health sector, which despite national and international efforts to control it is reproduced and perpetuated.

Taking these considerations on board, this study outlines the multilayered relationships, synergies and interactions that normalize corrupt practices in the health sector and make them part of the daily functioning and balance of the system. The results of our research presented in the following sections focus on the structure of networks, the techniques of rationalization and neutralization at micro and meso levels, the symbiotic relationship between corruption, financial and organized crime, and the symbiotic relationship between legality and illegality. However, before moving on to the analysis of the data, a brief reference to the methodology and design of the survey is required.

Research methodology

Beyond the extant research literature and a wide range of open sources such as official reports from international and national institutions and audit bodies this paper draws on a flexible programme of semi-structured in-depth interviews using a questionnaire by topic guides with open-ended questions (Mason 2011; Segrave and Milivojevic 2018). The analysis of the secondary sources provided among others useful information regarding the main typologies of corruption in health sector and further guidance for the development of the research tool. The questionnaire was also enriched from our preliminary findings from first interviews and adjusted to each interview. The researchers were free to follow the flow of the discussion, opening up new thematic areas, depending on the knowledge and experience of the interviewees, with no strict obligation to exhaust the questions or to follow a particular structure (Mason 2011). The main objective was to compile as much information, knowledge and perceptions as possible about the processes, relationships and structures that frame, reinforce and facilitate the phenomenon of corruption in the health sector, in order to gather the pieces of the puzzle and proceed to theoretical deductions and analyses.

The participants were selected through the snowball or referral sampling, whereby existing participants direct the researcher to future interviewees (Mason 2011). The criterion used was the respondents’ specific knowledge and experience with the issue of corruption in the health sector (Isari and Pourkos 2015; Tsiolis 2014) Based on this criterion, we selected as the first participant a public official belonging to the administrative inspection and control bodies with knowledge of the health sector. Starting with a representative of the administrative control authorities, we assumed that the referrals that would follow would include people with knowledge and experience of the health sector, as was indeed the case. In this way, access to closed professional networks was achieved, while prospective participants’ reservations were more easily addressed (Petintseva et al. 2020). The risk of biased sample composition, as participants refer to people in their wider professional and friendly circle with similar perspectives and perceptions, has been arguably mitigated by the referral to further participants from a variety of disciplines, specialties, and professional contexts. Indeed, the diversity of professional, scientific and professional backgrounds ensures the synthesis of a comprehensive picture of the field under investigation, since the perspectives and perceptions of individuals are combined with different culture, education, knowledge and aspirations (Isari and Pourkos 2015). The number of interviewees was determined by the degree of the saturation of the responses, which occurred when responses began to repeat and further interviews had nothing new to add to the information and perspectives already obtained (Mason 2011; Tsiolis 2014).

A total of 43 interviews was conducted including seven medical devices & pharmaceutical company executives, two health policy experts, five doctors, five pharmacists, two nurses, two brokers-sales representatives (medical visitors), eight officials of public health administration, three government officials, seven inspectors-auditors and two judicial officials. All the interviews were longer than an hour in duration while ethical issues related to anonymity, personal data protection and participant consent were addressed. Moreover, the research project was approved by the Research Ethics Committee of the Democritus University of Thrace.

In the final phase, after transcribing the interviews, we followed a process of coding and thematic analysis, based on research questions and processes of continuous layered comparative analysis of our data in order to place them into broader analytical categories (Boyatzis 1998; Clarke and Braun 2013; Davies 2018). The coding process was both descriptive and interpretive, revealing different aspects of the phenomenon. In this sense, we attempted to separate the data, which included information about processes, modus operandi, legal and institutional gaps, from personal judgments, evaluations and experiences. Then, through the continuous study and comparison of the data with each other and with our research questions, we moved from the codes to broader conceptual frameworks more abstract and general in conjunction with our theoretical assumptions (Tsiolis 2014; Mason 2011).

Findings

Overview of the Greek healthcare system

The Greek health care system faces chronic problems, gaps and weaknesses, which reinforce and facilitate corruption practices. In order to better understand these institutional deficiencies, a brief reference to the structure of the Greek health care system is required. The Greek health care system incorporates elements from both the public and private sectors. Public health services are provided by the structures of the National Health System (ESY), divided into primary, secondary and tertiary healthcare. Primary health care is provided by rural health centers and local health care units (ToMY), which belong to the Health Regions (Y.PE.) with a diagnosis and referral system based on General Practitioners (GPs) (Economou et al. 2017). However, primary care does not function effectively, especially in larger cities, while there is no link between primary care and hospitals. Secondary and tertiary health care is provided by both public and private hospitals and clinics (European Commission 2017).

Until 2014, health services were also provided by the insurance funds of various professional categories, which in 2011 were merged and consolidated into the National Organisation for the Provision of Health Services (EOPYY). EOPPY thus became the central ‘buyer’ and ‘payer’ of medicines, medical devices and services (Economou et al. 2017). Both the ESY and the EOPYY are financed by the state budget and the contributions of the insured to the Single Social Security Agency (EFKA). The Greek Ministry of Health is responsible for the planning and control of the NHS and the EOPYY. The private sector includes private clinics operating as for-profit organisations, diagnostic centers, laboratories and independent medical units. A large part of the private sector (doctors, clinics, laboratories) is contracted by the EOPYY, which is mainly reimbursing the services. Furthermore, medicines, medical materials, diagnostic tests and hospitalisation costs for insured persons are largely covered by the EOPYY, on the basis of a reimbursement list and depending on whether the healthcare is public or private.

Public funding of the health system has shrunk during the economic crisis (IOBE & SFEE 2020).Footnote 1 The reduction in public spending on health care has led to an increase in private spending and the passing of some of the costs to citizens. Nevertheless a known chronic issue in the Greek health care system has been the absence of rational allocation of financial resources, largely due to: (a) the lack of political will and of a long-term public health policy, (b) absence of an effective health management system at central, regional and local levels connecting needs and expenditures in the health sector, (c) the absence of an effective centralised procurement system, understaffing of the competent authorities (EKAPY), lack of knowledge and expertise of the competent committees, (d) the ex post parliamentary legitimisation of the exceptional procurement procedures of hospitals every year by law, (e) the delays in the reimbursement procedures by the Greek State (f) the absence of clinical requirements for medical devices, absence of medical protocols, absence of health assessment technologies for the evaluation and pricing of medicines and medical devices (Greece-OECD Project 2017), (g) the low salaries for public doctors, who after the decreases during the economic crisis earn on average 1,200-1,500 euros, leading to informal or additional payments from patients, false declarations about working hours, asking for benefits from providers. (European Commission 2017).

All the above have created a vulnerable environment fostering corrupt practices: in the absence of a long-term policy, a clear regulatory framework, an efficient system of controls and accountability, state actors create the background for such phenomena leading to a perpetual state-facilitated crime. Arguably, opportunities for corruption were rediced by institutional reforms undertaken under the financial stabilization programmes of the 2010s, such as: the consolidation of insurance providers, the e-prescription system, the price observatory for medical devices, the establishment of two Health Technology Assessment committees for the evaluation and pricing of medicines, the institutions of claw back and rebate for the control of pharmaceutical expenditure, the price list for medicines and hospital supplies, the registry for certain diseases, or the increase of controls(European Commission 2017). It is nevertheless interesting that corruption networks and practices have not been eliminated but rather adapted to the new circumstances (Chambliss 1988).

The structure of corrupt networks

Our interview data suggest that corruption practices are learned, assimilated and embedded through informal networks of relationships that are developed at vertical and horizontal levels. Corruption networks do not have a rigid structure and hierarchical character and are not dependent on specific individuals. They are formed, rotate and expand for profit. They are characterised by flexibility and adaptability, linked to each other by the cash flows and benefits secured in each exchange for the mutual benefit of all parties. The flexible and permeable nature of the networks makes them resistant to time and more difficult to detect. Therefore, the sustainability of the networks is based on the redistribution of profits to a large pool of stakeholders from politicians to nurses. These findings are largely congruent with other studies and theoretical conclusions that highlight the loose and dispersed structure of criminal networks (see Chambliss 1988; Paoli 2014; Morselli 2009; Granados 2021; Nielsen 2003; Jancsics and Jávor 2012, Hudon and Garzón 2016).

“The minister will get a share, the central system will get a share, the industry will get a share and that’s it. It’s clearly organized… it’s nothing by accident. No, the operation of the network doesn’t stop. …. the network continues… the network has never over the years actually stopped….it has been affected, only by the measures of the memorandum.” (Public Health Official).

Networks are developed at all levels, adapting to different typologies of corruption. Interviewees focus mainly on the networks created between doctors (private or public) and companies with the aim of over-prescription or directed prescription (drugs, materials, tests, referrals) and on the networks created within hospital structures concerning the procurement process of all kinds (drugs, consumables, medical devices, services.). In the first case, the networks appear to be developed at the horizontal level, while in the second case they are developed at the vertical and horizontal levels. This differentiation corresponds to the hierarchical structure of the hospital and the different responsibilities of medical and administrative staff. Thus, within the procurement process in hospitals, various stakeholders are involved such as: the director of the hospital, civil servants, members of procurement committees, physicians, clinic heads, medical supervisors, trainees, physician assistants, pharmacists, nursing staff.

“There are thousands of involved doctors…There are people involved who appeared as consultants at conferences giving instructions, advice, directions and presenting studies, that were supposed to be incorruptible. There were people involved from low, middle and higher levels… from different directions. I think there’s an omerta in the logic “don’t scratch me too much because I’ll scratch you, who are higher and if I scratch you who are higher, you’ll scratch someone else who is higher”. (Private Sector Executive)

Maintaining networks not only requires the involvement of a large number of people from the health sector but also securing the favour (tolerance or support) of the political system. Some participants, who worked mainly as sales representatives, medical visitors of companies, identified, among other things, monetary payments to political persons (MPs) not necessarily for a specific action but to support the party, as means of cultivating a favourable climate. This evidence suggests that the networks operate at several levels, crossing the social pyramid vertically and horizontally, creating clusters at all levels of the social hierarchy, to ensure stability and duration over time. It is a vertical and horizontal sharing of profits, extended from the lowest (administrators, paramedics, nurses) to the highest levels of administration and political power, acting as a veil of concealment and tolerance (Chambliss 1988).

“When I was working in the company, the boss also sent me to deliver envelopes (with money) to politicians (specific names of well-known members of parliament are mentioned). […] Look, I knew from the 90’s when I was working until the half of the 2000’s when I left, that both major political parties in power were “working well”. The company started in the 90’s as a limited liability company and went on to make billions in profits. [….] That’s why I said before that Greece at that time was El Dorado, the golden country and the golden time to make money.” (Sales Representative of Private Sector -Medical Visitor).

The initiative for building the network seems to be taken by companies, which include them in their informal organisational objectives. The interview data suggest that companies are drawing up a game strategy as if it were a basketball game and scoring players according to their degree of approachability. Those who cooperated were “the good guys of the companies”. Networks are also expanded with the contribution of the physicians themselves through extortionate practices and demands for benefits from the companies.

“It was mostly benefits that were legitimate. I mean, you go to a medical conference, they pay for everything, you’re basically taking a leisure trip,. Or you do a clinical trial -more for the professors this- and you get paid gold to get some negative results, which are often questionable. So they generally pushed for the drug to be prescribed… so they had these policies, these practices, which they had written down as manuals, with specific goals and guidelines . it was like going down to a basketball game” (Health Administration Executive).

The role of brokers such as sales representatives or medical visitors is crucial (Morselli 2009). Medical visitors are the companies’ people who are constantly visiting doctors’ offices and hospital structures recruiting new members. The approach is driven by the position and role of the physician or public official and their ability to take or influence decisions. Members are recruited into the network through the provision of benefits either directly, through cash kickbacks, or indirectly through various facilities. The latter is more common, due to its low level of detection. Companies provide their affiliated members with a range of benefits, from trips abroad under the pretext of attending training seminars, trips to exotic places to covering the expenses of the whole family, casino chips during educational trips, mobile phones, tablets, computers, books, medical equipment, renovation of professional offices and private houses, installation of flooring or air conditioning in medical offices and houses, changing tires of cars, but also payments for children’s studies. The companies were there to cover any need of the doctors and their families. Further, a common legitimate way of transferring money was to order clinical studies, often for drugs or materials that have been on the market for years. In this way, doctors’ percentages of sales were hidden within medical studies, while companies justified the kickbacks as research expenses.

“I was appointed to the health Centre (mentioned specific area) last September, I’ve been there a year now. So, I am not known to the circuit of this particular Health Centre. In the first month I was there, there was a knock on the door, a representative from a company came in, a company that sells, you know, pads for bedsores and stuff like that. And he said to me directly: “You prescribe our products and we compensate you” … The company approaches you, tells you if you prescribe the drug you’ll get a commission … The companies, you know, used to come to the hospitals and they still come and go to the pharmacies of the hospital asking how many boxes of their drug have been written and by which clinic. They know, let’s say, that in the ICU of that hospital they have approached that doctor. They go to the hospital pharmacy and see how many times the doctor has prescribed the drug…and they get their kickback accordingly.” (Public Health official and doctor).

The doctors’ acceptance of the benefits appears to be based on an implicit recognition of very low salaries that do not correspond to their professional status, but also on the indifference or incapability of the state to provide doctors with educational and training opportunities through the attendance of conferences. This practice has developed through the tacit tolerance and encouragement of the state, through the implicit assumption that the gaps in the state apparatus were being filled by private initiative (Green and Ward 2004).

“The truth is that it is difficult in this field to distinguish where the necessary and the normal and the legitimate stops and where the part of excess, or, if you like, of reciprocity begins. The benefits in question are normalized on the basis that the Ministry cannot afford to meet doctors’ needs for education and training” (Private-sector executive).

“That is, since for many, many years the Ministry of Health and the health budget in general has not covered such needs in medical staff, that is, the hospital does not cover money for them to go to attend a medical conference abroad, all these requests were and are being transferred to companies” (Private-sector executive).

At the highest levels of political power, recruitment techniques are not always distinct and identifiable in the sense that they do not necessarily refer to direct payments but to practices of a broader spectrum that may include offers of cooperation and professional promotion in the private sector (the revolving door phenomenon), political support but also lobbying through patient associations for the introduction of new medicines.

“I’ll tell you how the companies operate. Well, I was having coffee with my wife at one point. And I get a call from a guy, and he says, “Yes hello, are you Mr. Χ. ?“ I say yes. “Are you a lawyer?“ I say yes…. I was working as legal advisor at the Ministry at the time… “Yes, I’m calling from… (a name of pharmaceutical company is referred) and we would like a lawyer to represent us…"I say “where did you get my number?“ He says, “from the Yellow Pages.“ And I say, “You know, sir, there’s an obvious incompatibility because I work for the Ministry of Health?“ And he says to me…. “Oh, excuse me, excuse me, excuse me, we didn’t know it"….” (Health Administration Executive).

In some cases, networks are based on interpersonal relationships and acquaintances, as was mainly the case in the previous decades, before the economic crisis and before the entry of large multinational companies in the Greek market. Particularly in the 1990 and 2000 s, hospital doctors-maintained companies trading in medical devices, using their spouses or children as straw men. Thus, they used their personal professional network to promote their products with kickbacks. In fact, as one of our partiipants affirmed, the initial approach of doctors was made through informal and loose invitations (e.g., to a party, a coffee, a wine, an excursion) where the doctors became more familiar with each other by building trust-based relationships.

“They medical visitors were the ones who contacted the doctors plus the doctors directly knew the boss of each company. It was just the” medical visitor”, who was doing the “freshening”, such as “we’re here, and whatever you want Mr. Χ… you know the ‘big guy’ and you can talk to him, and all that… “. In our company, rarely the sales were done by the salesmen. The thing just rolled itself. If the boss was calling at the doctor’s office, he made a sale, straight away …. The conferences, the trips, generally the gatherings that private companies would normally hold, were a way to “break the ice” with many people in the field, to come together, to talk about what was going on, about new products, what was good, so that’s where it happened.” (Sales representative of company with medical devices).

Still, the network does not only involve relations between the various public and private sector stakeholders, but also relations between complex corporate structures and partnerships, between the parent multinational company and its subsidiaries. This fragmentation between organisational structures and individuals complicates the detection of networks even more (van der Does de Willebois 2011; Vassilantonopoulou 2014).

“Even their own associates in Greece did not perceive the profitability of the parent company from their actions. There is the parent company with branches in each country and the directors who are in contact with the parent company and there is the network of petty or grand corruption… the circle of the company opens up and there are other people doing the work and somehow the horizontal line of corruption from the parent company can be hidden …. the lines are dotted and the data is lost and everything runs smoothly for the companies” (pharmacist).

The following figure illustrates an attempt to visualise the complex structure of loose networks that operate at multiple levels, combining many institutions and players at vertical and horizontal levels. In the interaction of the above actors, enclaves of corruption are created on the basis of material exchanges and favours.

Fig. 1
figure 1

Interconnection of the involved actors

Full size image

Organizational subculture: techniques of rationalisation-neutralisation

Our interview data reveal an organisational subculture that is endemic in the health sector. In this field there is little empirical research, even though theory refers to organizational culture as an important variable in corrupt practices (Cambell et al. 2104). Specifically, the interviewees described the formation of a system of beliefs and attitudes, an organisational subculture that characterises not only those actively involved but also those who know about the corruptive practices and tolerate it. These beliefs seem to function both as techniques of neutralization and normalization of illegal practices (Sykes and Matza 1957). The logic of “everyone does the same” and or “that’s the way of doing business” acts as a veil of legitimization and normalization of the corrupt practices (Vikas et al. 2005).

The normalisation of illegal practices and their integration into an everyday practice is reflected in a logic of a self-evident right. Doctors seem not only to accept the unfair practices but to claim commissions from companies as if it were their legal right.

“That was a regime. I have spoken to doctors who say to me, ‘but well, aren’t we entitled to this money’? And when I told them, under what law are you entitled to it? the response is: “Okay, I may not be legally entitled to it, but at least I’m entitled to it.“ (Private Sector Executive– medical devices).

The building of this prone to corruption value system seems to have deep roots and starts very early, already during the years of studies in medical school. As a representative of a medical device company notes:

“At one point a professor of vascular surgery asked me to give a training course to a final year medical student who was about to go into vascular surgery. After a while, I asked him, “Are you okay? Are you keeping track of everything?“ He says, “I have a question. What percentage does the doctor get?“ I say, “What kind of question is that? What you’re asking me has nothing to do with the surgery.“ “Well, yes, I know, but isn’t the doctor entitled to 10%, maybe more, I don’t know,“ he says. I tell him, “That’s illegal. I’m not answering it.“ “But if he’s entitled to it, doesn’t he get it?“ I say, “I tell you, did you become a doctor to learn this first and then the procedures?“ “But,“ he says, “that’s how I know.“

This logic is directly linked to the underpayment of doctors’ salaries, as highlighted by several of the participants. It is also worth to note the expressed view that the low salaries of doctors constitute a kind of “informal agreement for the state to turn a blind eye to the doctors’ behaviour” (Inspector). The above subculture seems to permeate all levels of the hierarchy from the lowest to the highest. The belief that private gain characterizes the upper levels of an organization is reflected as a key reason for the reproduction of illegal practices at lower levels. In this way high corruption legitimizes petty corruption and vice versa. In other words, these are not two parallel independent processes but phenomena that presuppose and reinforce each other.

“Everyone in his own way. Because I steal and I have the power as the Head of the hospital or the Minister or the person in charge of large a scale procurement or of drug pricing process….and this is a large scale….very large amounts…and I allow at the same time the ones below (in lower the levels of the system) to steal something, to take a piece of pie” (Public Health Management representative).

At the same time, the process of rationalizing and neutralizing seems easier through the invocation of a higher purpose e.g., donation of an expensive machine for the hospital. (Matza 2004, Cohen 2001), where the benefit is not only reaped by persons but by the health institution itself.“ In this case it seems that the benefits for the institution neutralize and morally legitimize illegal practices. As it has been noted the very distance between an act and its ethical consequences (ethical distance) may also play a determining role in the neutralization process (Zyglidopoulos et al. 2008).

“A pharmaceutical company comes and tells you that " if you prescribe our medicine, you will also profit, but we will also build your clinic, renovate it, or buy you an ultrasound machine”. It is not necessarily a cash bribe, but they can bribe you in another way, which may be considered more painless, more innocent, more ethical. The logic is “let’s do it” and it will benefit science, benefit the clinic, it will offer to my doctors in practice, to learn, and eventually it will offer to patients’ through a modernization of the clinic’ (Doctor).

On the other hand, the culture of tolerance also governs the private sector, which has its own methods of punishing those who differ from the “flow of the system” and risk facing retaliation measures and an adverse career path.

“Because who will ask him back? Imagine a CEO in a large corporation, who in order to go to another one has to have references from the one he’s leaving, okay? He’s not going to get if the new company knows he blew up the last one! So, either he will decide to become a monk, put his diplomas in a locker and say: ‘ I am now changing my life paradigm completely’, or he will follow the flow of the system. These are not easy decisions to make. (Inspector-auditor).

Finally, it is important to note that through routinized and everyday practices, corruption seems to operate as a parallel system, an extra-institutional pole of power, an invisible partner of capitalist state, filling its gaps, contradictions and inequalities (Chambliss 1989; Gasparinatou 2021).

“It something like a parallel system…all these practices take in a context of a normality….it is the way that things happen…This parallel system of over profit is the hidden, invisible partner of the state…. Despite this over-profit and the illegal practices…. this system works properly and provides services, that the state cannot provide. I don’t know how this happen, but when you will need the valve, this will be there…” (Inspector-Auditor).

From the above is clear that unlawful practices are learned, rationalised and neutralised in the context of differentiate social interaction and the organisational subculture within corporate environments and health structures. In this context, contradictions in the dominant culture, competition, injustice, structural inequalities and double standards contribute to the neutralization process in interactional and organizational level (Matza et al. 2004).

Corruption, white collar and organised crime: a symbiotic relationship

An important aspect that has been highlighted by the participants in the research is the symbiotic relationship between corruption, white collar and organised crime. Prior research has illustrated that these are interconnected phenomena constituting a web of mutually reinforcing relationships (Chambliss 1988; Ruggiero 2000; Antonopoulos and Papanicolaou 2014; Antonopoulos and Tagarov 2012; Albanese 2018; 2021; Stamouli 2019). As Calavita and Pontell (1993) argue, the modus operandi of corporate misconduct approximates the organised crime model. Both crimes are based on a capitalist ethos of costs and benefits, both often express a cartel-type of criminality aiming to consolidate market monopolies (Reurink 2016). At the same time corruption often acts as an intermediate link, a stepping stone to economic and organised crime. Our findings confirm the close relationship between corruption and illicit business practices, such as market and stock price manipulation and fraud.

“Corruption is a tool for the multinational companies. Their target is the stock market… It is not a matter of interest for the A, B, C multinational company who is the responsible official of the A, B, C state that will have to pay them to promote sales. To me, I don’t think there is any sentiment, or preference, or ideological- political position……everything is numbers played on the stock exchanges. And that’s what sales are aimed at, which is… let’s say a company wants to appear to have sales of its pharmaceutical products, either at the state level because it supplies the state, or through the prescribing process by doctors. So, what does that bring? It will bring an increase in turnover… where? In its annual financial statements. But what are the annual financial statements? But it’s what investors look at to buy its stock. And that’s where the company will make money…. that’s where the major shareholders of the company are going to make money from.“ (Prosecutor).

It has been pointed out that financial and organised crime sometimes share expertise and adopt mutual techniques, services and benefits (Ruggiero, 1996). Corrupt networks, mainly at low levels, adopt organised crime practices such as the use of violence and extortion. In particular, several interviewees indicated cleaning and security services in health facilities as a sector that is almost monopolistically controlled by companies that adopt organized crime practices. This is largely due to the long-standing practice of hospitals resorting to outsourcing and contracting with cleaning and security companies instead of hiring permanent staff in hospitals (Moschuris et al. 2006). The contractors blackmail the workers and collect back part of their legal minimum wage as commission. The previous left-wing government attempted to break this regime, but without long-term results. These practices reflect to the Mafia’s activities in relation to networks of labour recruitment and exploitation (Jakobs et al. 2003).

“in pharmaceutical companies the play is different…. we are talking about giants and huge multinational companies. They do not usually adopt these practices. These big companies have other ways…. the way of kickbacks. The “underworld” is the smallest circuit. As it was let’s say the cleaning and the security companies…. there you see such more such violent practices…” (public health official).

“The system also adopts underworld practices. Especially in the cleaning sector…… well in this sector is obvious…. Yes…. there are bouncers that follow the cleaning staff to the bank machine in order the company to get its share- the proportion of their salary. They are extortionists …. in those categories such as cleaning, security services, catering, …they are extortionists- proper pimps. These groups are the most powerful. There is a monopoly and in fact when they were thrown out of the hospitals (as an outsourcing process), they threatened their employees not to get a contract, they threatened them, you will not exist, you will never work…it is an underworld.“ (Public Health Management representative).

“What was happening with the contractors in the cleaning …it’s well known this circuit. I remind you that KunevaFootnote 2“paid for” it with her face. The blackmail was directed at the workers. You don’t blackmail the hospital, you go to the administrator, and you tell him “you’re going to get five or six grand a month and it’s all good, right”? To the employees also. They were told that cleaners were getting 700 euros a month, they were taxed for 12,000 euros a year, and they were pocketing 450.“ (Public Health Official and Doctor)

Participants also mentioned that the practice of threats is adopted also by company sales representatives or by doctors. In the first case, such practices aim at maintaining control of a hospital and a network of relationships. On the other hand, the unfair extortion practices are also noted to be adopted by doctors to the company representative.

“Bribery is not necessarily exclusively bribery, but often takes the form of extortion. That is, I’ll take yours if you give me that much. If you don’t give me that much, I’ll get it from somewhere else” (Private Sector Executive).

The close and symbiotic relationship between corruption, white collar crime and organized crime is also emerged from the above description of the network’s structure and function. The respondents described a network of informal payments and money transfers, with an organizational and organized character. The network is characterized by a business logic, and its activity falls in several cases in the gray areas of the economy and appears as a regularity (Ruggiero 1997, 2007; Hall and Antonopoulos 2016).

Policy capture and favourable practices in pharmaceutical policy

The interviewees also highlighted issues relating to the clinical assessment, the pricing and marketing of medicines. The practices of pharmaceutical companies mostly take place in grey areas at the borderline between legality and illegality and aim at the collaboration or tolerance of top political officials through practices of guided lawmaking, political capture and to cultivate a favourable political environment (Braithwaite 1984; Rawlinson 2017; Baker 2019). Τhοse practices largely escape the attention of the criminal law, even though they cause social harm and lead to high social costs. As Kramer and Michalowski have stressed, big multinational companies use their economic power and political influence on co-shape with political actors a favourable legal framework (Kramer and Michalowski 1987). This is a modern form of economic colonialism, which is strengthened by the fact that large multinational corporations make their policies in global basis (Friedrichs 2007; Lasslett 2017). Having an insight into how the market operates at global level, they can influence national regulatory frameworks by exerting pressure on the market using legal or illegal means.

To understand these practices, which often escape criminal law, a brief reference to the assessment and pricing process of drugs in Greece is necessary. Globally, drugs are divided into on-patent, off-patent (usually after 10 years) and generic. Medicines have 3 different reference prices: (a) the list price, (b) the reimbursement price which is the insurance price covered by the state and (c) the retail price of the medicine in pharmacies. However, in many countries, which have sophisticated systems for evaluating and negotiating medicines, another reimbursement price for the state is decided after negotiation, which is confidential. These procedures are not so developed in Greece (Golna et al. 2005).

Τhe maximum ex-factory price of an on-patent medicine marketed for the first time in Greece is determined by the average of the two (and before 2019 of the three) lowest prices of the same product in the Eurozone countries (Souliotis et al. 2016). According to this external reference pricing (ERP) system, Greece was a reference country for determining the price of the medicine in other countries, while pharmaceutical companies have the global overview of the market. The off -patent price is again calculated from the average of the two (formerly three) lowest prices of the EU, while generics are priced at 65% of off patent. The law also provides for a reduction in pricing depending on the content of the active substance.

Furthermore, the pricing process requires the opinion of the National Organization for Medicines (EOF) to the Minister of Health. The EOF (Positive List Committee), posts a draft of the Pricing List, on which objections are raised by the companies and then submits its opinion to the Minister. The latter also consulted the Ministry’s Drug Price Negotiation Committee (abolished in 2017) before issuing the relevant ministerial decision. In 2017, two committees were established, the Assessment Committee and the Negotiation Committee in a Health Assessment Technology logic, which to date have not been functioning effectively.

According to interviewees, the illegal practices of pharmaceutical companies could take various forms such as, pressures on the political leadership for higher pricing at the initial launch of the drug, even of a few euro cents, which is translated into very high profits at the global circulation. This is achieved through the price calculation system with reference countries. Companies can control in which countries the drug will be launched first, which affects the global price. Thus, they have an interest in releasing a drug at a high price in a country with a loose legal framework or in a country that can influence the initial price.

On the other hand, pharmaceutical companies, having the global market overview, may cause artificial withdrawal of a drug from reference countries when it is about to be imported/priced in another country, in order not to affect the new pricing. In addition, the research participants point out that the pricing of medicines was based on the list prices of the reference countries and not on the reimbursement prices, which are the result of negotiations with each Member State and are confidential. Consequently, the reference country prices for calculating the average of the three or two lowest marketing prices in EU countries are higher than the actual reimbursement price in the list. In other words, the deductions made have a fictitious and not real nature.

“The important thing was that we were reimbursing with the list prices, and we didn’t have a real clinical evaluation of drugs in Greece, an HTA mechanism. All drugs were included in the positive list based on pricing rules that were not fair in terms of reimbursement policy. For example, this case with Lucentis and Avastin, I don’t know if you’ve heard of it? They put Novartis’ Lucentis into the system against Roche’s Avastin. Avastin, which was already on the positive list and had the same therapeutic effect, made 35 euros. And they put Lucentis in with a price 200 times higher, I don’t remember now 650 or 500 euros … Meanwhile, because Novartis owns 30% of Roche’s shares, Roche itself was not promoting its drug.” (Government Official).

The companies’ illegal practices are also reflected in the pressure they exert on public officials and politicians asking for favourable repayments. This is very important considering that the large bulk of drugs are reimbursed by the state, which implements horizontal policies to reduce pharmaceutical expenditure, such as Claw back and Rebate systems. Preferential reimbursement of one company over others can imply anything from financial survival to the capture of a dominant market position.

The interviewees also note issues relating to omissions in the (re-)pricing of medicines by reference to the content of the active substance. This phenomenon can be observed in both on -patent and generic medicines. In the latter case, it is probably done with the tolerance of state actors, on the basis of a long-standing and implicit will to support the Greek pharmaceutical industry, which produces the majority of generic medicines. By the same token, the high pricing of generic drugs (65% of the off-patent prototype), which is quite high compared to other countries, is maintained as an indirect way of supporting the Greek pharmaceutical industry and the low penetration of generic drugs in the Greek market. In this direction, two participants in the survey highlighted the way of calculating the insurance reimbursement of medicines based on an algorithm, which is calculated by a private company and delivered to the EOF. They point out that there is little scope for checking those calculations of the insurance price by reference to the quantity of the active substance.

Finally, this research also raises issues such as political capture and guided legislation through interdependencies between companies, politicians or political parties (Nelken and Levi 1996). These are various forms of political corruption, which takes place in sophisticated ways at the legislative stage, particularly in the pricing of medicines. Participants often mention the Novartis case but at the same time they also highlight practices of circumvention of the law through channels and persons with multiple roles and responsibilities that fall within the typology of conflict of interest and the revolving door phenomenon, i.e. persons who were at the same time advisors to both companies and ministers. On the other hand, they stress the link between private capital and the political system through the underground and opaque financing of political parties (Gasparinatou 2019).

As described by an executive of a MedTech company that was involved in a 7-year legal battle with the state over the award of a public tender:

For some years there was certainly involvement of successive Ministers of Health .... was a multinational company, which was coming into consultation with all the Governments ... [describing a tendering process with objections and a legal challenge to the Council of State] ... after 7 years now, the case reaches the Council of State ... we run like crazy, we reach up to the Minister at the time, we show what is happening, there is a complete apathy and indifference and suddenly ... a contract is awarded as a result of the tender to the company that was excluded from the tender and the contract includes items that were not offered in the tender (!) ... A large group was involved at the time ... When we reached out to get Legal Counsel, a man who was very close to the then Minister, because we saw that it was a political issue, we were told out the window that: “Guys, don’t make efforts, don’t make expenses, there’s no point, it’s on another level of understanding”. This multinational company had drugs, it had diagnostics, it had very strong ties with a number of Ministers of Health, and basically for a period it did what it wanted...

“…it is difficult to prove …but there is funding for political parties to create a favorable environment, favorable decisions, favorable pricing, favorable priority debt repayment …everything is there…but usually it is not in exchange for a specific action…but a larger situation…we are here and we support you… so, support us too.” (Inspector-auditor).

“…100% there was also shadow funding of the parties. Of course . They saw at some point that in Greece, because the framework was too loose, they had a lot of room for profitability. They were then also bringing out new drugs…. and then what did they do? They took someone from telecommunications, who knew various politicians….“ (Government official).

Discussion

Our findings illustrate the fluid and pervasive nature of corruption in the health sector in Greece. The integrated theoretical model of state-corporate crime drives the analysis away from monistic and narrow approaches, opening up new fields of discussion. It highlights the complexity of the phenomenon, the interdependence and interaction of multiple levels of social action within the political economy of neoliberal globalised capitalism. In this perspective, the mutual interplay of incentives, opportunities and social control is examined as catalysts that operate reactively at individual (interactional), organizational and institutional levels, reinforcing each other. In this way, the culture of competition and profit-making conceptualises individual motivations and organisational goals, while it rationalises and normalises the use of illegal means.

On the other hand, although our research focused on high corruption and the procurement process, the theoretical model of state-corporate crime allows us to even understand the relationship between grand and petty corruption, revealing their mutual reinforcing process. This happens not only because the tolerance levels of stakeholders at different positions are increased, but mainly through the interconnection of money flows. Thus, for instance, the prioritisation of surgeries on the part of doctors, for the benefit of specific patients, simultaneously prioritises and determines the hospital’s supply needs. Thus, the financial flows that develop at the interactional level affect flows at the organizational and institutional levels.

More precisely, the research data demonstrate that the techniques of rationalization and normalization of corruption are learned in the context of social interactions (Sutherland et al. 1992), within loose social networks and within organizational contexts. Corruption networks are flexible, permeable, resistant to time and thus more difficult to detect (Jancsics and Jávor 2012; Hudon and Garzón 2016). They have no rigid or hierarchical structure, and they are based on the distribution of profits to all stakeholders from nurse staff to political officials. Through personal contacts and relationships that develop at horizontal and vertical levels, either through direct contacts between private or public doctors and representatives of medical and pharmaceutical companies or within the structure of public health units (hospitals, local health units), doctors and health care officials learn that they are ‘entitled’ to a sum of money from the companies’ receipts as compensation for demanding or prescribing the product.

Corruption networks are formed at the initiative of companies and are built either on the basis of personal relationships, in the case of a doctor who owns a medical device company through a surrogate relative, or through brokers such as sales representatives and medical visitors. Pharmaceutical and medical companies include the building of a network of affiliated physicians among their key corporate objectives by keeping records of the names and sales percentages of each. Depending on the sales rates, the doctor’s position and title in the scientific community, the amount of the exchanges provided is also determined. The illegal exchanges can be direct, either in the form of cash transfers or indirect benefits such as office equipment, educational trips or coverage of family expenses. They may further take place covertly as indirect payments for controversial medical studies used as a cover for illegal payments or even include offers of career promotion and career opportunities in the private sector. As discussed above, companies are looking for people in key positions working as consultants in ministerial offices in policymaking or procurement committees, who by playing a dual role can easily promote their policies to decision-makers. Political capture in this case takes place through such experts and consultants who are both advisers to ministers and consultants to companies, acting as a bridge between the public and private sectors.

The recruitment strategies of companies, which aim to expand their turnover and to gain a dominant position in the market, are not opportunistic and random but are part of the informal latent objectives of the companies, the organisational goals and corporate culture. These are activities that fall within the concept of ‘organisational deviance’, ‘organisational crime’ and in particular ‘corporate crime’ (Clinard and Quinney 1967; Ermann and Lundman 1978; Schrager & Short 1978; Braithwaite 1984; Harding 2007) as they: a) deviate from both the broader regulatory framework of society and the company’s formal objectives; b) correspond to the company’s unofficial but accepted objectives and are thus facilitated or supported by the company’s management; c) are part of the deviant culture that develops within the company, which includes law breaking techniques, rationalisation and neutralization processes. As such, job positions within the organisational context are linked to specific roles and expectations to which social subjects are required to adapt if they wish to remain and advance within the company (Schrager & Short 1978; Shover 1978). Indeed, as the research points out, an employee’s opposition to the unlawful practices of companies may deprive him or her of their entire career as ‘who will ask him back [….] if the new company knows he blew up the last one! So, he will decide to become a monk, put his diplomas in a locker [….] or he will follow the flow of the system’.

Learning and adaptation techniques in organisational contexts are not only related to private sector executives but also to public sector executives. As significant scholars have shown (Sykes and Matza 1957; Cohen 2001), techniques of neutralization take various forms and alternate. Social subjects through logical and social processes deny, disclaim and justify their responsibility, passing the blame on to a superior (obedience), to the system’s modes of action (conformity), to a higher purpose or necessity (Sykes and Matza 1957; Cohen 2001). In this regard, physicians and public health officials normalize unlawful practices either by denying knowledge of their unlawful nature, by denying the harm they cause, by invoking the common practice of the organization, or by invoking a higher purpose. Thus, for instance, they believe that they are entitled to some commission for the medical supplies and drugs they use and prescribe, that it is a common, expected and legitimate thing to do, and that all doctors, health care units as well as the health market operate in the same way. At the same time, their low salaries from the state and the state’s inability to cover their justified and necessary training and education costs reinforces their belief that they are rightly and legitimately asking the private sector to meet these needs. The invocation of a higher purpose does not only concern the personal educational needs of medical staff, who must be constantly informed and trained on the new achievements of science. It can also be about meeting an organisational goal, such as modernising a health unit or a hospital, or installing new equipment or computers. In this case, the medical and pharmaceutical industries are always willing to fill the gaps of the state apparatus and the lack of state funding, while doctors and public health officials, respectively, easily justify, neutralise and rationalise their decisions, as long as they are taken to protect the public interest, to train medical staff and to upgrade health units.

Through the above processes, moral resistances at the individual and organisational level are broken down, rules are delegitimised and a new normative cultural framework, a new moral code, is dialectically built at the individual and organisational level. The stakeholders are not often aware that they are breaking the law, but rather that they are adapting to the subculture of the organizational context and its cultural normative code (Passas 1990; Vaughan 2007). in this context, corruption is not just an individual deviation of some civil servants or business executives, it is not only linked to specific individuals, but is gradually embedded in the structures, in the daily functioning of organisations, in the daily work programme, in the informal code governing the functioning, objectives and performance of the organization (Vaughan 1982, 2007). The normalisation and institutionalisation of illegal practices, which sometimes solve bureaucratic problems or even financial constraints, is also implicitly inferred from the persistence and sustainability of these phenomena. The faces change but the corrupt practices remain. Therefore, it seems that social subjects adapt to the latent functions, organisational culture, goals and objectives of business actors and state governance bodies. They are the product of the interaction of social institutions on the congruence of values and aspirations. The content of the common normative code that constitutes the common platform for social action and operation of the public and private sectors, is made meaningful by the broader value framework of society, its economic and political structures, while at the same time being facilitated by the absence of control, accountability and monitoring (Gasparinatou et al. 2022).

Extending this reasoning, Tombs (2012) argues that the States and corporations are increasingly in a symbiotic relationship, which leads to the systematic and daily production of crime and social harm. In many cases, separating ‘state interests’ from ‘corporate interests’ is highly problematic due to the intertwined agendas of those at the top of both the state and corporate hierarchy (Tombs 2012: 175). The coincidence of interests and the shared worldview of these executives is also reflected in the ease with which they alternate between high-level positions in the public and private sectors, constituting the revolving door effect (Roth and Kauzlarich 2016: 124). According to Tombs’ analysis, the state does not simply fail to control the multi-level social harms of corporations. The latter are not the result of simple omissions or the failure of formal social control to regulate private initiative. Rather, they are part of a broader understanding of the functioning of the state and the economy, a broader hegemonic common sense that is expressed, created and reproduced through law and policy (Tombs and Whyte 2015: 92). In fact, it is a symbiotic relationship of legality and illegality on the shared ideological hegemony of gaining profit and benefit without limits and preconditions. The exponents and enforcers of the law collude with or facilitate those who violate it. (Chambliss 1978/1988). Our evidence shows that the symbiotic relationship between politics, law enforcement, legitimate business and corruption (Chambliss 1988: 154) is absolutely necessary for the survival and flourishing of corruption in the health sector, as has been the case for decades in Greece.

Notably, as discussed above, the cash flows from the pharmaceutical and biomedical industry do not only reach public or private sector doctors, health structures or administrative staff, but also cover the political system through the underground financing of political parties or specific politicians in order to ensure tolerance and support in the distribution of public money or in the decision-making and policy-making process. Interviewees describe various forms of political capture. From simple forms of transferring money to political figures through envelopes exchanged hand in hand between company and parliamentary representatives in the 1990s to more sophisticated practices in the marketing approval and pricing of medicines today. With regard to the latter, it is important to note that companies attempt to influence the legislative process through officials with a dual role, acting as both consultants to ministers and advisors to pharmaceutical companies. On the other hand, a hidden link between politics and capital is often implied in the interviews through the shadow funding of political parties in order to favour certain companies. However, it is important to point out that this link, while pointed out by research participants, often with reference to the judicial evolution of the Novartis case, is very difficult to prove with concrete evidence.

Despite the difficulties of proof that may arise, it is obvious that state actors cooperate, promote, encourage, facilitate or tolerate the unfair practices of capital, either in the name of a direct retributive benefit (political support, political funding) or in the name of economic growth, in the sense of increasing economic capital and profit rather than social welfare. Consequently, the inability of the state’s inspection bodies to control and combat corruption is not only due to institutional weaknesses and chronic shortcomings. It reflects the implicit tolerance of these phenomena on the basis of common goals and objectives.

In this respect, it is no coincidence that the disclosure of major scandals (e.g. Novartis) occurs mainly when an opposing pole of power is affected and reacts (Chambliss, 1988). Then certain sections of power rally in order to delegitimise the opposite power poles, leading to a redistribution of economic and political power. It is like a shuffling of the deck, but without changing the terms of the game (Gasparinatou 2021). As a result, the investigation of the relevant cases never gets to the heart of the system, to the exposure of the informal networks that support them, their interconnections with the state apparatus. This is because in such a case it would cause a general destabilisation of the system and its economic and political structures. Investigations always come to a point. Moreover, in a paradoxical way, the efforts of governments to combat the crimes of the powerful further legitimize the system. This is because the focus of public opinion and the criminal justice system returns to the safe space of individual responsibility, covering up the larger mechanisms and structures that enhance them (Roth and Kauzlarich 2016).

On the other hand, it is important to note that corruption in the health sector in Greece develops and flourishes in a symbiotic relationship not only with legality but in a symbiotic relationship with white collar and organised crime (Vidali 2017). All three categories of crime presuppose a system or subsystem of power that supports them, they have a relational, organisational and organised character, and they have common elements in terms of their modus operandi, their conditions of occurrence, their conditions of expansion, their social impact, their relationship with the law and with power (Vidali 2017:130). In the present case, it appears that the kickbacks and the amounts illegally circulated are justified as expenses for medical studies or staff travel and training costs or even as legitimate marketing expenses in the annual financial statements of companies. This false presentation of financial data is completed by the presentation of the increase in sales turnover, which is achieved through the illegal practices of distorting competition. Through these practices, companies aim to manipulate shareholders and increase their economic power on international stock exchanges.

Furthermore, white-collar crime practices are being followed by the techniques and networks of organised crime, mainly at the lower levels of service provision in health structures. In this direction, and according to the findings of the research, in the cleaning and security services of hospitals, which are provided by external companies through outsourcing, there are practices of violence, extortion, blackmail and widespread labour exploitation. Besides, as has been pointed out by several studies and scholars, (see Chambliss 1988; Ruggiero 2000; Antonopoulos and Papanicolaou 2014; Antonopoulos and Tagarov 2012; Albanese 2018; 2021) financial and organised crime often exchange and share techniques, services and benefits, and often act as connecting vessels in the grey areas of the economy, reinforcing each other (Ruggiero 1996).

In concluding this study, it is important to note that all interviewees emphasized the structural and systemic nature of corruption in the health sector, which is institutionalized and embedded in the power nexus and the state mechanism. The reproduction and perpetuation of the phenomenon raises questions about the latent functions of corruption in the reproduction and consolidation of existing power relations and further in the operation and balance of the system in general.

In particular, moving from Merton’s analysis (1968), the functions of social structures can be (a) functional, when they act in favour of the adaptation, regulation and maintenance of the system, (b) dysfunctional, when they contribute to the deregulation of the system and (c) non-functional, when they are indifferent to the system (Merton 1968:90). At the same time, they are divided into ‘manifest functions’, which are embedded in the formal objectives of the structures, and latent functions, which are not part of their direct/manifest objectives but contribute to the maintenance of the system. However, some social structures fail to perform the manifest functions that make up their legitimating/ethical background. This fact, however, does not seem to affect their existence and maintenance, in the sense that they neither disappear, nor are they changed, nor are they merged. In this case, the functional claims of a system or a part of it may be carried out not only by formal institutional channels, but also by informal/alternative structures of an extra-institutional character, which are respectively linked to latent social functions (Merton 1968). Merton analyses these informal structures through the concept of the ‘political machine’, to which he ascribes the extra-institutional rallying of dispersed sections and poles of power in the central economic-political structure. In this way, on the one hand, the gaps and dysfunctions of social structures or institutions are covered, and, on the other hand, conditions of social consensus are created in relation to the terms of economic and political organisation of the dominant system (Merton 1968). These conditions are achieved through a variety of processes and functions, which use vertical and horizontal structures, formal and informal networks of clientelism, exchanges and favours (Gasparinatou 2019).

Following this line of thought and from a Mertonian perspective of view it could be argued that corruption functions as an informal and extra-institutional branch of power, which, through latent functions, resolves conflicts and structural contradictions, acting as a stabilizing force for the structures of capitalism. Under this perspective corruption operates like the lubricant that fills the gaps in the joints of power while reducing the friction from structural conflicts of capitalism (Vidali 2013). It is a phenomenon of a permanent, organisational and organised nature that operates in a symbiotic relationship with white collar and organized crime and with legitimacy itself, to the extent that it requires and presupposes the collusion of state actors (Chambliss 1988, 1989, 2004). Our research aspires to open up new fields of research and reflection in this direction.