Corruption and Public Procurement in Health Sector: The Challenges of Pandemic Era in Greece

Abstract

The health sector in Greece is considered as one of the most vulnerable sectors with high levels of corruption and appears to be particularly problematic in the provision of health services and in medical supplies procurement processes carried out by public hospitals. Viewed from a systemic-structural perspective, corruption is examined as a phenomenon emerging from the interactions and interconnections between the organized structures of venture capital and the state apparatus. This paper argues that the COVID-19 crisis has produced a breeding ground for potential corruption practices and seem to intensify the unlawful practices especially in procurement processes. The state of exception and the implementation of emergency measures manufacture the conditions that permit the lack of transparency in the transactions between the health care system and the pharmaceutical industry. Applying an integrated theoretical model of state-corporate crime and critical health criminology and drawing on empirical qualitative research, this paper highlights the procurement corruption risks in the health sector during the pandemic era.

Keywords

corruption state-corporate crime critical health criminology public procurement COVID-19

Introduction

Corruption constitutes a persistent problem in the health sector, with negative impact on health status and social welfare systems (Vian, 2008). A range of organisational factors contribute to making this sector susceptible to corruption of both petty and grand types (Slot et al., 2017). 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 (Albisu Ardigó & Chêne, 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 practices that serve as building blocks, for example from bribery, extortion and kickbacks for public contracts, to fostering a favourable environment or direct or indirect benefits, and all the way to stronger influence of manipulation of procurement procedure, guided legislation, and policy capture. According to Transparency International, the areas that are particularly exposed to corruption incorporate: 1. provision of services by medical personnel; 2. human resources management; 3. drug selection and use; 4. procurement of drugs and medical equipment; 5. distribution and storage of drugs; 6. regulatory systems; 7. budgeting and pricing (Albisu Ardigó & Chêne, 2017). Similarly, corruption seems to steer necessary funds away from key fields, such as the healthcare sector, making each country more susceptible to the onslaught of a pandemic. Furthermore, emergencies such as COVID-19 create leeway for the non-transparent allocation of resources, which further drives the country into a healthcare crisis. An emergency poses as the perfect alibi for uncontrolled procurements and opaque allocation of funds (Transparency International, 2021).

In Greece, corruption is considered a prevalent phenomenon. According to the Special Eurobarometer 523 on public attitude towards corruption (2022), 98% of respondents think that the problem of corruption is widespread in Greece. This is the highest percentage among the 27 EU countries, followed by Croatia and Cyprus with 94%. Moreover, the vast majority of Greek citizens (94%) strongly identify corruption in public institutions, with the corresponding average in the 27 EU countries being 74%. The 93% think that too close links between business and politics in Greece lead to corruption, while nine in ten consider that corruption is part of their country’s business culture.

As far as the health sector is concerned, 91% believes that bribery in the healthcare system is prevalent (EU average: 27%). This can also be confirmed by Transparency International, where in their 2021 Corruption Perceptions Index, Greece placed 58^th. Transparency Internationals’ report on Greece found issues with actions against high-profile corruption, as well as with public procurements. The audit that was implemented resulted in the issue of fines reaching approximately EUR 954,950 and the suspension of 109 business actors (Policy Department for Citizens’ Rights and Constitutional Affairs Directorate-General for Internal Policies, 2022). The health sector is particularly recognized as one of the most vulnerable sectors to corruption along with tax and customs administration, local government and defense sector, according to the National Anti-Corruption action plan NACAP 2018-2021 (2020).

The corruption in the health sector was intensively underlined in public discourse during the economic crisis that Greece has suffered since 2008. It was during the same period where anticorruption narrative became a key issue and a priority of the governmental agenda. A Parliamentary report points to a causal relationship between the two, whereby the Greek fiscal crisis was in part caused by the inordinate expenses of medical supplies and the corruptive practices in health sector which then came under judicial and parliamentary scrutiny (Hellenic Parliament, 2018). Especially the Novartis Case constitutes a high-profile corruption investigation launched by the FBI and the USA Justice Department (United States v. Novartis Hellas S.A.C.I, 20-cr-00538 (USA Vs. NOVARTIS HELLAS S.A.C.I, 2020). The investigation revealed that employees of the subsidiary of the Swiss pharmaceutical company paid bribes to numerous public officials and private doctors in Greece in order to patronage and to increase the sale of pharmaceutical products (GRECO, 2022; OECD., 2022). According to 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 and the public loss from the illegal practices of all pharmaceutical companies is estimated at €23 billion (Dima, 2018). The investigation concerns the possible involvement of high-ranking politicians and it has been the subject of intense political debate which is partly reflected in both the social sphere and the judiciary. For some politicians and political parties, the case is a political conspiracy to exterminate political opponents. On the contrary, for another portion of politicians and political parties, it is a typical case of state-corporate crime involving political and other forms of corruption, violation of medicines prices and guided legislation (Chrysopoulos, 2019). The case was also announced to the Working Group on Bribery¹ as a typical case of foreign bribery (Kathimerini Newspaper, 2022; OECD, 2022b). The Greek Government filed a lawsuit in June 2022 to hold Novartis accountable for bribery of former government officials and healthcare providers (Kathimerini Newspaper, 2022). Moreover, the DePuy case has an international impact and involves a large number of actors. The case refers to a subsidiary of Johnson & Johnson, supplier of orthopedic medical devices (USA v. DePuy Inc. Crim. 11-cr-00099-JDB eVs, 2011) which according to USA court decision gave to Greek Health Care Providers and Greek Agents improper payments that were approximately $16.4 million.

However, despite the fact that the high corruption in the health care system in Greece constitutes a potential fertile ground for research and analysis, the few studies that have been carried out focus mainly on informal payments made by patients (e.g., to expedite surgeries, or facilitate access) (Giannouchos et al., 2021; Liaropoulos et al., 2008; Souliotis et al., 2015; World Health Organization (WHO), 2018). The high corruption practices in the health sector that are found mainly in the system of supplies (medicines/medical items) and in particular in the procedures of procurement (of goods, services, biomedical products, equipment, medicines) are under-researched.

The paper aims to address this lack of research by focusing on the corruption practices in public procurement processes in the health sector especially during the pandemic era. Our claim is that the emergency condition of the pandemic acted as a catalyst for corrupt practices (Atiles Osoria, 2021; Cepeda Cuadrado, 2020; OECD, 2020), especially in the particular vulnerable field, where risks of corruption are always current (European Commission, 2020; OECD, 2007).

We approach the corrupt practices in public procurement in the health sector not as an occasional or isolated phenomenon but as a phenomenon of a systemic-structural nature (Tombs, 2012). Moreover, we aim to show the entangled links between the state of emergency, corruption and state-corporate crimes as well the criminogenic impact of the COVID-19 pandemic. In the following sections we present the theoretical framework and the research methodology, followed by the presentation and analysis of our findings with a focus on the typologies of corruption in public procurement and on the impact of the pandemic as a state of emergency.

Theoretical Framework

On the Symbiosis of Corruption and State-Corporate Crime in Public Procurement: The Challenge of the COVID-19 Pandemic

Corruption is a sociological term that refers to behaviours, practices, acts, omissions that are grouped as a broader phenomenon which affects both administrative and democratic function. Mostly present in organizations and professional frameworks, (Ashforth & Vikas, 2003) these behaviours, in their majority, have a relational nature and involve a wide range of activities and actors (Diviák et al., 2019). The abuse of entrusted power so as to gain private (individual or organizational) benefit is in all cases, the core of corruption (Transparency International, 2021). The systematic nature of corruption moves beyond the conceptualization as individual deviancy, and is better depicted in the state-corporate crime perspective. The common goals and objectives shared by private/business actors and public/governance actors creates an interdependence and interrelation between the two which is commonly demonstrated in white collar crimes and crimes of the powerful (individual or organizational).

This “mutually reinforcing interaction of policies and practices” (Aulette & 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); a) the state -corporate crime initiated by the State, which occurs when the company-contractor hired by the state is involved in organizational crime or illegal acts under the direction or acquiescence of the State; b) state-corporate crime facilitated by the state and occurs when the control mechanisms of the state fail to limit or halt the deviant or criminal business either because there is a direct collusion-partnership of the business with the government- or because they end up accepting the complaints (acts or omissions) of the enterprise in order to prevent more severe consequences (Kramer et al., 2002, p. 272)

The state-corporate crime paradigm is used to examine how the state, as a regulating actor, interacts with the profit-seeking corporations. Under this perspective the high corruption in the health sector is approached as the serious cases of irregularities on the part of multinational companies in cooperation, collusion or tolerance of public sector representatives and services (Barak, 2017; Chambliss et al., 2010; Friedrichs, 2010; Friedrichs & Rothe, 2014; Kramer et al., 2002; United Nations Office on Drugs and Crime, 2020, 2021). A particularly vulnerable sector is the system of procurement and management of medical supplies in public hospitals (procurement corruption). Globally, 10–25% of public health spending (medical devices and pharmaceuticals) is lost on corrupt practices (World Health Organization (WHO), 2007, p. 1). Public procurement is a multi-stage process, which involves first assessing the needs, drafting the terms of the tender notice and publishing it, then conducting the tender, awarding and selecting a supplier, and finally signing the contract and monitoring its implementation. In general, the public procurement process can be divided into three phases: (1) before the tender or before the submission of tenders, (2) during the tender or during the submission of tenders and (3) after the tender or after the submission of tenders. Corruption can occur at all stages of the contracting process. Before the competition the most common categories are:

• Corruption in assessment of needs (induced demand or excessive need)

• Circumvention of the bidding process

• Pre-arranged bidding

During the tender:

• Bribery during the evaluation of the bid

• Favouritism

• Collusion and/or division of the supply

After the tender or its submission:

• False invoices

• Change of terms

• Featured: (1) Bribery to doctors: (a) money, (b) travel, (c) entertainment, (d) favours to relatives, (e) offer discounts (2) Bribes to medical institutions: (a) money, (b) participation in conferences, (c) free provision of materials, (d) research funding and other forms of sponsorship (European Commission – Directorate-General Home Affairs, 2015, p. 63).

In the case of pharmaceutical industries, Braithwaite (1984) suggests self-regulation on top of criminal law to combat corruption cases. However that neoliberal factor doesn’t seem to work. State-corporate crime is extremely common, as the legal systems are often used by those in economic power for their benefit. In the particular discussion, the focus is usually on the side of the state, and less on the corporate side that benefits from the corrupted procurement process. As a result, there is a risk of analysing the phenomenon without collecting all the necessary data. Said data can range from corporate ownership and management information to the relations between companies and their personnel which contribute greatly to finding out how these companies communicate with each other and create conspiracy networks (Hudon & Garzon, 2016; Nicolás-Carlock & Luna-Pla, 2021).

In this paper, we follow the critical health criminology context in the COVID-19 pandemic era introduced by Friedrichs and Vegh Weis (2021, pp. 126–146), based on which state-corporate crime takes advantage of the pandemic in order to mask the crimes of the powerful in the healthcare industry. One characteristic example is the US healthcare industry, which tends to operate more based on profit than on illness (Rosenthal, 2020), while hospitals resemble a company selling products, rather than a service providing a basic human right (Friedrichs & Vegh Weis, 2021, p. 135). The pharmaceutical industry in the US is also akin to a “criminal enterprise” with exploitative and corrupt practices (Braithwaite, 1984; Posner, 2020) without being persecuted thanks to its ties to the public sector (Friedrichs & Vegh Weis, 2021, p. 137). During the pandemic, the pharmaceutical industry lobbied to deter the implementation of measures to control the price of upcoming COVID-19 vaccines and drugs (Zaitchik, 2020), while members whose pharmaceutical companies were developing COVID-19 vaccines were selling their stocks at a much higher price (Gelles & Drucker, 2020). Through this, it becomes clear that the pandemic provides an opportunity for committing “invisible”, high-profile state-corporate crimes that have an effect on people’s health and society, but also creates a need to finally uncover these crimes and bring them to light (Friedrichs & Vegh Weis, 2021, p. 132).

The state corporate crimes amidst the COVID-19 pandemic in the US were facilitated from tax incentive policies in order to boost the economy, as well as the use of the state of exception for emergency procurements. One such example is the testing kits that would be distributed in the US and Puerto Rico by Abbot and Roche, two large transnational corporations. While Puerto Rico had provided adequate corporate welfare in order to be distributed testing kits, in the end these corporations did not provide the necessary equipment to manage the virus, resulting in a vicious cycle of low testing, and thus low levels of contagion, which in turn calls for less testing kits, since the supposed low contagion levels do not require them. This suggests that the two corporations showed no social responsibility, while simultaneously benefitting from Puerto Rico’s tax haven economy (Atiles Osoria, 2021, pp. 114–115)

Simultaneously in the UK, government corruption during the COVID-19 era can be traced easily through the pandemic emergency provisions (Coronavirus Act analysis, 2020). For example, personal protective equipment (PPE) was the scapegoat for various procurement contracts to corporations with no history of PPE manufacturing. A similar case is found in regards to the COVID-19 testing kits, as well as the track and trace system of the virus. Soon, the corrupt contracts spread further than the emergency procurements for COVID-19 and the government seemed to prioritize clientelism and cronyism above public health. This pattern of state corporate crime in procurements can be found in various countries (US, Slovenia etc.), thus shedding light on a pattern of contracts and unchallenged tenders being given to corporations linked to government supporters, resulting in a failed attempt to provide services. The use of COVID-19 as an excuse to bypass normal procedures is something that all governments have in common, masking the state corporate crimes under a veil of emergency. Furthermore, while direct corrupt practices are not reflected in the policies themselves, the crime can be understood in the economic and social sphere, as these state corporate schemes sacrifice the safety of the population for the gain of the social and economic structures informing capitalist society (Gordon & Green, 2021).

Moreover, the structural violence fueled by state corporate crime becomes apparent through emergency policies for COVID-19. The issue that arises is the fact that state corporate crime is not always identified as such, with a distinct example being the neoliberal shrinking of the public healthcare system that ultimately results in preventable deaths for disadvantaged citizens. Another issue with structural violence is that it is usually slow and steady, making it hard to identify the shocking ramifications. In the case of COVID-19, the budget cuts to the public healthcare system constituted a gradual structural violence that COVID-19 deaths uncovered (Gordon & Green, 2021). As Green and Ward (2004) suggest, state crimes should be viewed as “human rights violations perpetrated by states through both over-reach and under-reach to advance personal goals”. This also falls in line with the notion of “essential crimes”, in the sense that state-corporate crimes are essential for the powerful and the wealthy to remain as such, even at the cost of national healthcare (Vegh Weis & Magnin, 2021, p. 274).

Critical criminology offers a promising framework for the examination of these state-corporate crimes, suggesting a “critical health criminology” that researches the relationship between governments and pharmaceutical industries (Goldacre, 2013) and its impact on the population (Friedrichs & Vegh Weis, 2021). One such case was the opioid crisis in the US that created an “economy of death”, a phenomenon that can easily describe the US state’s response to the pandemic. Ultimately, the pandemic uncovered the state corporate crimes that have been happening long before COVID-19 hit and are neither natural, nor inevitable. These crimes show the power relations (Ruggiero, 2015) as well as reproduce them, and through the critical health criminology framework we are able to understand their historical roots and also identify previous corrupt interactions between governments and corporations as what they really are: state-corporate crimes.

Empirical Research Methodology

The paper draws on qualitative research methods, such as anonymous interviews and desk-based research (e.g., annual reports of the audit and law enforcement bodies and the Hellenic Single Public Procurement Authority, the parliamentary report on the investigation on scandals in health sector, the National Action Plan against Corruption, international reports and surveys (UN, OECD, WHO, EU, etc.)). The analysis of the secondary sources provided useful information regarding the main typologies of corruption in health sector and further guidance for the development of the research tool, the questionnaire for semi-structured interviews. A total of 43 semi-structured in-depth interviews (Mason, 2011; Segrave & Milivojevic, 2018) were conducted, including seven medical devices & pharmaceutical company executives, two health policy experts, five doctors, five pharmacists, two nurses, two brokers-sales representatives, eight officials of public health administration, three government officials, seven inspectors-auditors and two judicial officials. Interviewees were selected through purposive sampling (snowball or referral sampling), using the criterion of respondents' specific knowledge and experience with the issue of corruption in the health sector. 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 bias has been arguably mitigated by the referral to further interviewees from a variety of disciplines, specialties, and professional contexts. 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).

Throughout the research implementation, the ethical framework that governs the qualitative methods of social research was followed and the interviewees were informed about the object of the research and the identity of the researchers (Mason, 2009, pp. 123-130, 373–379), in order to fully consent to the use of their interview data. The participation was entirely voluntary, and they could withdraw at any point in time (Mason, 2011, pp. 79-80; Noaks & Wincup, 2004, pp. 74–89). During the empirical research, the ethical – legal framework for the protection of personal data (including EU Charter of Fundamental Rights, General Data Protection Regulation (GDPR) – Regulation (EU) 2016/679) was followed, while the ethics plan of the project was previously approved by the relevant ethics committee of the university.

Corruption in Public Procurement During the COVID-19 Era: The case of Greece - An Overview

Public procurement has been identified as one of the high-risk sectors in Greece (NACAP 2018–2021). According to the Flash Eurobarometer 457 (2017), almost three-quarters of the surveyed companies perceive public procurement managed by national authorities to be corrupt. On the other hand, almost four out of five companies believe that procurement managed by local authorities is corrupt. More than half of all companies believe that corruption has kept them from winning a public tender contract in the last three years. The most common reasons are:

• The criteria seemed to be tailor-made for certain participants (20%);

• Collusive bidding (19%)

• The deal appeared done before the call for tender was published (17%).

Lastly, more than half of Greek individuals consider officials awarding tenders as corrupt (Risk, Portal, Compliance 2020).

According to the Eurobarometer 482 (2019), 33% of Greek companies believe that corruption has prevented them from winning a public tender or a public procurement contract in the last three years. The percentage is close to others European countries (EU 28, 30%). In this field we can observe a significant change comparing with the results of the 2017 Eurobarometer, with a decrease of 19 percentage points (from 52% in 2017 to 33% in 2019).² Instead, the 2022 Eurobarometer (507) presents a remarkable increase (+14 points) compared to the 2019 figure (European Commission., 2022a), where 47% of Greek businesses consider that corruption has prevented them from winning a public tender or contract in the last three years (17 points higher than the average in EU-27).

It seems that the impact of COVID-19 has affected the processes of public procurement further and has produced a breeding ground for potential corruption practices (Bruce, 2020; Sforza et al., 2020). More specifically, the Greek government adopted general measures in response to COVID-19, mostly in the form of exceptional Acts of Legislative Content. The use of Acts of Legislative Content is restricted in exceptional cases of extreme urgency and unforeseeable necessity and is provided by the Greek Constitution (article 44 par. 1).³ The Acts of Legislative Content are issued by the President of the Republic and are legally binding rules equivalent to ordinary parliamentary laws (Kouroutakis, 2016). The particular form of “emergency law” is immediately effective and expires within 40 days of enactment if the government does not present the Legislative Acts to Parliament for ratification before then or if the Parliament fails to ratify them within three months. The article 44 constitutes one of the two basic institutional provisions that “provide distinct emergency response frameworks, and bestow a wide range of executive powers upon policymakers so they may respond accordingly” (Kouroutakis, 2016). The other provision is article 48 (“state of siege”) of the Greek Constitution, which provides the normative description of the emergency state and is applicable to threats to national sovereignty and security from foreign or “internal” adversaries of the State. The State is allowed to suspend civil rights and liberties in these uncommon circumstances (Karavokyris, 2020). Thus, article 44 of the Greek Constitution is applied in times of crisis (in peace time) other than the crisis described above in article 48, and in more detail in extraordinary circumstances of an urgent and unforeseeable need, such as natural disasters or socio-economic disruptions. During the time of financial crisis the particular “emergency law” turned out to be a useful tool for “fast-track” legislating (Karavokyris, 2020). This practice of the systematic adoption of legislative acts in the period of the fiscal adjustment programs (Memoranda) without fulfilling the substantive conditions for their issuance received severe criticism. Especially, in 2012 the Greek Government has extensively used “emergency” law-making power provided by Article 44 causing “a significant clash between the government’s and the people’s perspectives on what deserved emergency treatment” (Kouroutakis, 2016). During the particular period, the most crucial pieces of legislation were not a product of consultation and public debate.

On the other hand, the COVID-19 pandemic constitutes a major global public health emergency and undoubtedly an unforeseeable circumstance that established an unusual “emergency” law, which introduced restrictions on a number of constitutional rights (Karavokyris, 2020). In the area of public procurement, exceptional legal provisions were introduced in order to legalize emergency procurement processes. Thus, since March 2020, any contracting authority under the responsibility or supervision of most of the Ministries may carry out their procedures for the supply of personal hygiene or collective protection through outsourcing in derogation of any relevant provision of public procurement. The same process is also followed for other fields in the public sector, such as the supply of equipment and software to support the needs of online education. Moreover, the National Organization of Public Health may enter into contracts for direct outsourcing to private healthcare providers (diagnostic laboratories). According to the Hellenic Single Public Procurement Authority – HSPPA, under emergency circumstances, it is allowed not to publish a tender, as long as it is adequately justified. Furthermore, the tender doesn’t need to have a specific price threshold (Hellenic Single Public Procurement Authority, 2022). This provided a dangerous opportunity to exploit the state of exception for individual gain. Other Legislative Content Acts introduced urgent arrangements for the response of the National Health System against the spread of the coronavirus by providing the possibility of conducting emergency procurement procedures for medical devices and diagnostic tests for COVID-19, in order to immediately meet the needs for tests/medical devices through the examination of biological material of suspected cases.

It is evident that the pandemic created emergencies that needed effective, timely and flexible “solutions”. HSPPA stressed that these solutions should be followed only for the necessary time and to the absolutely necessary extent and should remain within the EU legal framework, which offers a series of flexibilities and possibilities.⁴ In this context, HSPPA has issued a series of explanatory documents and guidelines related to the award and management of public procurement for tackling the health crisis of the COVID-19 virus. A crucial initiative towards safeguarding the integrity and transparency in Public Procurement is the modification by the HSPPA of the e-transparency Platform (KIMDIS) to include new fields regarding direct award and negotiation without prior publication on the grounds of COVID-19 extraordinary legislation, while at the same time offering data extraction, impact assessment, auditing and Public Procurement system monitoring.

Despite the above efforts, there are some allegations that the government is using the above urgent legal framework “as a pretext to rush through highly opaque and questionable public-finance deals” (Fotiadis, 2020). For example, there have been some serious allegations of corruption regarding direct assignment of public contracts to politically friendly companies by way of derogation from public procurement procedures. This is not related only to the health sector but a wide range of public sectors, where a series of direct contracts to private companies opened the discussion on the legal fulfillment of the procurement process, and raised questions regarding the lack of transparency and the corruption risks (Syntakton Newspaper, 2021). Characteristically, we refer to a series of direct contracts to private companies by the General Secretariat for Anti-Crime Policy (Ministry of Citizen Protection) that has raised serious questions regarding the lack of transparency. In more detail, the opposition party denounced the General Secretariat for Anti-Crime Policy as an “industry of direct assignments”, as in December 2020 rapid test supplies were held in order to cover the needs for the Detention Centers of the country. As it was referred in the press the 9240 rapid antigen detection tests were procured at a price of 450% more expensive than the factory price and 1,230,000 gloves with latex powder, at a price of 75% more than similar orders by other public bodies (Syntakton Newspaper, 2020). Similar issues have been raised by the opposition party also for other direct assignments by the particular Ministry, such as the supply of masks and antiseptics in November 2020 (TVXS, 2020).

Research Findings

The typologies of corruption in the health sector reflected in national and international reports are confirmed by our research findings (European Commission, 2020, Greece-OECD Project: Technical Support on Anti-Corruption, 2017). As recorded in our research, the typologies of corruption can be mainly found in three levels: a) in the relations of patients and physicians (health care providers), b) in the relations between private sector officials (pharmaceutical and medical representatives, companies, promoters), doctors (public or private) and pharmacists, which influence to the process of prescribing and c) in the relations between business actors (representatives of medical-technological and pharmaceutical companies) and high ranking public officials, who take decisions at central level, with an impact on the legislative and central health policy process.

Regarding the procurement system process, we find typologies in the supplies of medical devices, medicines, materials (e.g. gloves, syringes, catering) and services (cleaning, storage, technical support) in health structures. The lack of an efficient centralized procurement system leaves room for tailor-made call for tenders, segmentation of quantities, so the procurement rules do not apply and direct assignments (almost 80% of supplies) with opaque criteria. 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 who were not controlled by anyone for the use and necessity of these products.

In this field, there some factors that seem to be contributive, such as the:

(a) artificial demand,

(b) the lack of electronic recording and monitoring of inventory-consumption at both local/regional and central level,

(d) the diversified prices of medicine and medical-technological items and products in the Hospitals of the Territory,

(e) ambiguities and legal gaps in the operation of the hospital regarding the practice of consignment.

The establishment and operation of a centralized procurement system was identified by the majority of participants as one of the important issues to address the phenomenon of corruption in the health sector. The lack of will was identified as one of the main factors why centralized procurement tendering procedures for procurement seem not to have worked so far. Competition between companies is also highlighted as one of the main reasons why attempts to conduct centralized tendering procedures have not been effective so far. As a prerequisite for conducting centralized procedures in the field of procurement, the rational organization of the system and centralisation of material specifications is underlined.

On the other hand, the questionable effectiveness of establishing centralized procedures for procurement was underlined reflecting the risk that centralized tendering could prove less competitive for large companies because of the huge administrative costs or, on the contrary, that it could prove competitive only for the big players and exclude the smaller companies.

Corruption in the COVID-19 Pandemic Era

Ιn crisis conditions, including the COVID-19 pandemic, an “exceptional” context is created which becomes a normalized situation (Atiles Osoria, 2021), in which the boundaries of legality and illegality become blurred. All the participants of the empirical research argue that the pandemic crisis was the vehicle for the expansion of corruption phenomena in the health sector.

“The intensity of the corruption phenomenon increases in times of crisis, because the safety valves and the control loosen, let’s say, by invoking the inelastic needs that arise. So the intensity of the phenomenon is increasing, because corruption certainly existed before, but the intensity is greater in crises” (Representative of Audit and Judicial Authorities).

As the research participants highlighted, the pandemic has turned the public procurement system in the health sector to a completely uncontrolled field. As it was mentioned, in the health sector there are already a large percentage of direct assignments (almost 80%) through divisions or by invoking urgency and immediate danger for the public health. As a Representative of Public Health Management reported, “they introduce provisions that obviously give legitimacy to unfair practices”. As such, it becomes apparent that the state of exception brought about by COVID-19 introduces a new normalcy through the implementation of laws and regulations that would otherwise be out of legal boundaries. These new laws legitimise the expanse of power to key authorities, thus normalising the emergency governing (Young, 2022, p. 239).

Another interviewee stated that during COVID-19, ICU beds were outsourced to private clinics, which then overcharged for each bed that was provided; “[…] at the beginning of COVID-19 the needs for intensive care units were outsourced to the private sector at the highest cost they could charge for patients who would have to be treated in the public sector. All ICU [intensive care unit] beds were turned to covid-19 ICU beds. The clinics took huge sums to cover needs outside the public system”. This occurrence proves the benefiting relationship between the public and the private healthcare sector in a neoliberal environment, where the former creates favourable circumstances for the latter.

Furthermore, in regards to donations, a relationship of dependency is created between the benefactor and the recipient, at which point the latter is obligated to continue purchasing from the benefactor’s company:

“[…] this [phenomenon] in the COVID period has been somewhat bypassed. […] there have been donations of equipment, machinery placed in hospitals and therefore at this time hospitals are committed to purchasing materials from the companies whose equipments were donated” (Private Sector Executive participant).

The use of COVID-19 as a state of emergency for the urgent demand of procurements, from linear accelerators that do radiotherapy to mattresses is apparent. The pandemic was used as a “mask” to hide the state-corporate crimes in the healthcare sector in Greece and paved the way for corrupted tenders and competitions with no questions asked.

“[…] the system is designed to allow them, and even more so in the last year of the pandemic it has taken on formal dimensions, because by way of derogation from every provision, procurements are made in the name of COVID. Even the mattresses […] What is happening right now from the last self-tests to what has been done in the pandemic, the disinfectants, the simplest things that exist on earth, […] gloves, masks, everything is exploding” (Representative of Audit Authorities).

A characteristic example is described by one of the interviewees, who states that each purchase of a new machine was explained as an emergency need under the Covid-19 pandemic, even if that specific machine had nothing to do with the pandemic itself:

“He wants to get different machines which he includes - for all machines the reason is COVID. All of them. Which are irrelevant to COVID. He wants to get a water sample to control the linear accelerators that do radiotherapy (Private Sector Executive participant).

This can be corroborated by Dimitrios Papadimoulis’ question in the European Parliament about large-scale derogations. In his question, it was stated that “in the name of emergency” the Greek government passed regulations introducing exceptions, while public tenders were either restricted (17.5%) or directly awarded (13.9%). It is very interesting that of the 13.9%, only 1.7% is directly linked to the pandemic (European Parliament, 2022). The answer given by Mr. Breton on behalf of the European Commission stated that Greece never notified the Commission about the national measures relating to the EU Public Procurement law, and as such should do so by September 2022 (European Parliament, 2022).

Using the “exceptional” context of the pandemic (Appadurai, 2020) and within the fluid limits of legality and illegality, the phenomena of corruption and state-corporate crime have adapted to the way the capitalist market is structured today (Coles, 2020) and have developed relevant techniques in their field of activity. In particular, according to the interviewees, a new environment of anomie was formed, which includes “pre-agreements” between the political power and companies through “fix-made contests”. These “fix-made contests” of the procurements are evident by the way they were carried out in relation to the ‘capabilities’ of the companies and the market, since, as mentioned in the interviews, only through a “pre-agreement” could a company have millions of rapid tests or masks ready for supply. A representative of the private sector-biomedical industry talked about the rampant corruption regarding the tender for the supply of rapid tests. The specifications of the tender, along with the short deadline left no room for other bids besides the company it was aimed at:

“[…] The competitions held by the Institute of Pharmaceutical Research and Technology on behalf of the Ministry of Health for the supply of rapid tests have many scandalous issues […] Our Association complained about this to the Ministry […] A tender about two months ago for the supply of 2,000,000 tests. It is announced on Wednesday with the closing date of the submission of the offer on Friday, two days only, with specifications that were tailor- made for only one company […] and with a delivery requirement of the products within 3 days from the signing of the contract. Which company in Greece, if it does not know in advance that there will be a tender, has 2,000,000 tests in stock to deliver them? And the specifications themselves essentially left no room for others […]”. This falls completely out of legal bounds under normal circumstances, according to the aforementioned Directorate-General Home Affairs’ standards of a tender (European Commission – Directorate-General Home Affairs, 2015, p. 63, p. 63)

Similarly, a Pharmaceutical Sales Representative reported their experience regarding a tender for the supply of protective masks:

“The situation in the last year has left room for corrupted practices: negotiated contracts […] I know this based on a case. The proposal he submitted, for how many millions of masks, he was told that: you have to bid, it was Friday, for Monday. And he says: let’s say I send it [the bid] to you, how will I have them ready by then? […] . The offer was to be given by Friday for Monday and next Friday the masks would have to be ready. We’re talking about 6 million masks”.

Tracing the Techniques of a Lawful Institutionalized Corruption Regarding Procurements During the COVID-19 Era

In the lawful institutionalized corruption there exist state-facilitated corporate crimes (Michalowski & Brown, 2020), in which specific selection criteria are activated in legislative acts that favor specific companies and exclude the rest of the market. Based on the results of the empirical research and what the interviewees reported, an illustrative example is the case of “Ministerial Decision No.DI/G.P. 75342. Government Gazette 5198/Β/24-11-2020 “Specialization of the necessary diagnostic characteristics of the medical devices of rapid antigen tests SARS-CoV-2 (rapid test), identification of public and private bodies, which can use similar type of medical devices for diagnostic or epidemiological purposes and specific categories of persons who undergo this specific diagnostic test” (2020), which was subsequently amended, in which the criteria included that “Medical devices should be listed by the World Health Organization”. Αlthough this list is advisory and not binding, it was included in the above Ministerial Decision. According to interviewees, under this criterion, one of the largest procurement for millions of rapid tests, in essence rewarded certain companies that met this criterion and threw out the rest of the market. A Private Sector Executive shared an example of a corrupted procurement for COVID-19 tests whose competition included shady criteria:

“[…] This year worked for COVID-related materials, as if we had no public procurement. […] whoever wanted to, bought whatever he wanted. Suddenly the country made a deal with an American company to procure, probably be given a number of tests to Greece for COVID, then a competition followed for which much has been heard, much has been written. That [competition] was for […] 5 million, 8 million tests? […] which has a term in it that doesn’t make sense: for the materials to be listed in the World Health Organization list. This famous World Health Organization list contains only 2 items […] and essentially only allows these two companies to participate. It's a tailor- made criterion that leaves out the whole market […]”.

The above “COVID exceptional” context in relation to the way in which the corruption and state-corporate crime phenomena are shaped (Atiles Osoria, 2021), is accompanied by the elimination of control mechanisms, remaining in the “dark” side of the crimes of the powerful (Barak, 2015; Rothe & Kauzlarich, 2016; Whyte, 2009). The avoidance of criminalizing such acts could be because of the alleged necessity of capital accumulation and the interests of the capitalist state, or simply because the institutions making these emergency regulations are closely connected with the benefitting recipients (Vegh Weis & Magnin, 2021, pp. 275). According to interviewees, this is because:

“[…] whoever you accuse, will come back and tell you: […] what I put, I did so in order to be approved by the World Health Organization. Do you disagree with the fact that WHO knows what it’s doing, knows what it’s saying? If we went to any Court, it would be a lost cause. Because, reasonably, ask anyone on the street: by who do you prefer the product to be certified? By EMA (European Medicines Agency) or by WHO? But in an environment like the European market, these things should not happen. I would, for example, agree to talk about something approved by the European Medicines Agency […]” (Private Sector Executive participant).

Simultaneously, through the empirical research findings, the issue of product quality (Steingrüber & Gadanya, 2021) is highlighted. Public procurement during the coronavirus is carried out on the basis of the “lower price” of the product, as well as, through the above “informal agreement” between the State and companies. As the interviewees highlight in regards to this “informal agreement”, procurement on the health sector should be based on criteria such as products with “specific characteristics” and being on the WHO list are preferred in order to choose specific companies and exclude others, this does not mean that these products are of high quality.

“The state buys based on the lowest price, does not buy based on the best product. What we call the most advantageous price […] lower price means that the one who has the American [product] will not sell anything. Which means that the state's intervention on these issues is negative […] There are many models in Europe that control the product in terms of quality etc. […] There was a competition for the reagents and because they wanted to get some specifically, in consultation with the company of course, because the company is the one that opens their eyes, it [company] said “write that it should be on the WHO list”. But the World Health Organization does not guarantee quality. WHO waits first to be given the marketing authorization in some countries and then says that “I’m putting these on my list”. The WHO list is not a quality assurance item, but because it was convenient to get these products at that moment, just put the WHO list to be done with it” (Private Sector Executive participant).

In regards to pricing, procurements are assigned through tailor–made tenders based on the lowest price, but this creates distortions, because when the equipment arrives, more money is needed in order to install them, which means that in the end they are more expensive. This specific incident occurred with procurements from China, that turned out to cost more because the installment process was separate from the price of the procurements themselves.

“[…] A procurement of respirators is coming, right? They got the lowest price, one [supplier], I think the supplier was from China, […] they didn’t put the price for the installation of the machines in this part, right? So, I have to make another contract with a local agent, to install the machines, so the machine will be more expensive in the end. […] they would pay at the cheap price, but in the end, it turned out to be more expensive because machines had to be installed, so they had to pay more money for the installation. I think such mistakes have been made […] I probably noticed in the rapid tests, that [competition] is given a lot, right? That is, the Region took out a competition for rapid tests, right? where it was tailor- made! Completely! With a specific company. This really needs to be checked!” (Private Sector Executive participant).

Most of the interviewees link the corruption and state-corporate phenomena with the inactivation of the control mechanisms, which in turn allow for the skyrocketing of the price of supplies, such as gloves and masks. Various Acts of Legislative content effectively disable the control mechanisms and subsequently facilitate the relative companies. A Private Sector Executive participant reported the issue with the Court of Auditors and the price observatory being overruled due to the emergency exception of the COVID-19 pandemic:

“Now our Audit is over, so we have no subject. Because if there was the Court of Auditors and the price observatory, they would not pass any of the assignments made by the current government now, which buys gloves at ten times the price I find in the neighborhood supermarket” (Representative of Audit and Judicial Authorities). That is why I say that the observatory must have a price range, it cannot be the same. […] take a look at the gloves they buy with personal protective equipment […] Because the acts of legislative content that have been issued now abolish the observatory. Theoretically they say that [they are justified] in violation of all applicable legislation due to urgency […] (Private Sector Executive participant).

All the above framework, according to the participants, produced “new” social harms (Ken & Leon, 2021; Michalowski & Kramer, 2007), as a part of the “COVID-19 state-corporate (crime) business”.

Concluding Thoughts

The area of public procurement in health represents a vulnerable sector where a range of high corruption typologies can appear. 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 entities co-shape the market of medicine and medical devices by affecting the demand and the pricing. The inappropriate “marketing” practices between the industry and health professionals are a fertile ground for corruption with a direct impact on prescribing, approving process of drugs and medical devices. This constitutes a grey area between legality and illegality and as an interviewee states “It is inevitable that there are gray areas […] so the law will always leave room […]”.

The participants in the research highlighted the corruption in the health sector as a stable phenomenon, which constitutes an integral part of the reproduction of power structures within the existing economic and political nexus. As an interviewee (Official of Public Health Administration) stated: “It’s something like a parallel system...all these practices take place 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.” Thus, 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. It also creates a new normalcy, solidifying the existing power relations through “exceptional” regulations. Additionally, Sismodo introduced the term “epistemic corruption” in order to describe how pharmaceutical companies corrupts medical science (Sismodo, 2021).

The research also revealed that the COVID-19 pandemic has contributed to the expansion of the state-corporate criminal practices, which already existed and characterized the way that the health sector operates. The state of emergency introduced exceptional procedures which raised concerns particularly in relation to contracts and direct awards that seem to not fulfill the transparency requirements. As the latest official figures from the Hellenic Single Public Procurement Authority (HSPPA) show, the amount of direct awards and closed tenders over the last two years has now exceeded €7.5 billion⁵, which has prompted public debate and questions from the opposition regarding the allocation of public money (Syntakton Newspaper, 2021). The normalisation and institutionalisation of the state of emergency is apparent. In particular, the public institutions and the government continue to invoke the emergency situation improperly, in order to expand public procurement by direct assignments, without transparent and merit criteria, bypassing the tendering process. The above situation justifies the increase of percentages for Greece in the latest Eurobarometer for Businesses’ Attitudes towards Corruption (European Commission, 2022b), where the 47% of Greek businesses consider that corruption has prevented them from winning a public tender or contract in the last three years (there is a remarkable increase (+14 points) compared to the 2019 figure and 17 points higher than the average in EU-27).

The article addresses the need to incorporate to the studies of critical criminology the relationship between the health care systems and the pharmaceutical industry under the concept of state-corporate crime. Moreover, the approach of the pandemic as a criminological phenomenon is a useful analytical tool to feature more aspects of the pandemic impact. Our findings may also lay the foundations for future research and documentation to further investigate the entangled links between the state of emergency and other aspects of corruption and state corporate crime, as well as the conditions under which the exceptional context becomes normality.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Hellenic Foundation for Research and Innovation, 2377.

Notes

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