Updated study on corruption in the healthcare sector : final report.
Date: 2017-09-27
Institutions: Directorate-General for Migration and Home Affairs
Subjects: corruption, fight against crime, health care, health care system, health expenditure, health policy, medical device, pharmaceutical product, public contract, report

Updated Study on Corruption 
in the Healthcare Sector 

Final Report 

Written by Ecorys Nederland B.V.,  
September – 2017 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Authors 

This study has been undertaken by a team of experts of Ecorys Nederland B.V.: 

Dr. Brigitte Slot 

Linette de Swart, MSc LL.M.  

Kim Weistra, MSc 

Dr. Wija Oortwijn 

Niels van Wanrooij, MSc 

Tess Raets, MSc 

EUROPEAN COMMISSION 

Directorate-General for Migration and Home Affairs 
Directorate D — Security 
Unit D.3 — Organised Crime and Drugs Policy  

Contact: Kalin Ivanov 

E-mail:  Kalin.Ivanov@ec.europa.eu  

European Commission 
B-1049 Brussels 

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Updated Study on Corruption in the Healthcare Sector  

Updated Study on Corruption 
in the Healthcare Sector 

Final Report 

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EUROPEAN COMMISSION 

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DISCLAIMER 

The information and views set out in this report are those of the author(s) and do not necessarily reflect the 
official opinion of the Commission. The Commission does not guarantee the accuracy of the data included in 
this study. Neither the Commission nor any person acting on the Commission’s behalf may be held 
responsible for the use which may be made of the information contained therein. 

More information on the European Union is available on the Internet (http://www.europa.eu). 

Luxembourg: Publications Office of the European Union, 2017 

ISBN 978-92-79-73245-4 

doi:10.2837/68580 

DR-01-17-966-EN-N 

© European Union, 2017 

Reproduction is authorised provided the source is acknowledged. 

2017 

EN 

Directorate-General for Migration and Home Affairs 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Table of Contents 

Executive Summary .................................................................................................... 9 

1. 

INTRODUCTION ................................................................................................. 21 

1.1.  Background of the study ............................................................................. 21 
1.2.  Scope and objectives of the study ................................................................ 22 
1.3.  General approach ...................................................................................... 23 
1.4.  Outline of the Final Report .......................................................................... 24 

2.  METHODOLOGICAL APPROACH ............................................................................. 25 

2.1.  Survey ..................................................................................................... 25 
2.2.  Thematic interviews ................................................................................... 26 
2.3.  Fact finding missions .................................................................................. 28 
2.4.  Desk research ........................................................................................... 29 

3. 

COUNTRY STUDIES ............................................................................................. 31 

Introduction .............................................................................................................. 31 
3.1.  Greece ..................................................................................................... 32 
3.2.  Croatia ..................................................................................................... 45 
3.3.  Lithuania .................................................................................................. 53 
3.4.  Hungary ................................................................................................... 65 
3.5.  Poland ..................................................................................................... 77 
3.6.  Romania .................................................................................................. 89 

4.  UPDATE SHC1 AND THEMATIC DEEPENING .......................................................... 103 

4.1. 
Introduction ............................................................................................ 103 
4.2.  Update SCH1 .......................................................................................... 104 
4.3.  Thematic deepening ................................................................................. 130 

5. 

CONCLUSIONS ................................................................................................. 143 

5.1.  Revisiting the general conclusions of SCH1 .................................................. 143 
5.2.  Relevant developments since SCH1 ............................................................ 145 
Annex I: Interview guide .......................................................................................... 149 
Annex II: Overview of survey stakeholders .................................................................. 153 
Annex III: Survey design .......................................................................................... 167 
Annex IV: Corruption indicators (Special Eurobarometer 397) ........................................ 183 

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Updated Study on Corruption in the Healthcare Sector  

ABSTRACT 

In 2012, Ecorys conducted an initial study on corruption in the healthcare sector (SCH1).1 
The purpose of the current study on corruption in the healthcare sector was two-fold: (i) 
to analyse and report on relevant developments since the publication of SCH1 and (ii) to 
provide  an  in-depth  analysis  of  selected  issues:  privileged  access  to  medical  services, 
improper marketing and potential risks involving double practice. 

The study covered all EU-28 Member States, with specific attention focused on: Greece, 
Croatia, Hungary, Lithuania, Poland, and Romania. The analysis is based on desk research, 
an  online  survey  sent  to  stakeholders  across  the  EU,  thematic  interviews  with  various 
organisations  in  the  field  of  (EU)  healthcare,  and  fact-finding  missions,  providing  more 
detailed analysis and examples with regard to the six selected countries. 

The study concluded that: 

  Bribery in medical service delivery remains one of the main challenges, especially 

in many Eastern and Southern European Member States.  

  Corruption  related  to  granting  privileged  access  to  healthcare  or  potential  risks 
involving double practice are not isolated to Member States with a high perception 
of corruption (in healthcare).  

  Transparent procedures are key in addressing corruption in procurement processes. 
  Attempts to address improper marketing increase at both EU and national level.  

1 SCH = study on corruption in healthcare  

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Updated Study on Corruption in the Healthcare Sector  

SYNTHESE 

En 2012, Ecorys a mené sa première étude sur la corruption dans le secteur de la santé 
(SCH1).2 L’étude actuelle sur la corruption dans le secteur de la santé visait 2 objectifs : 
(I) Analyser et faire état de l’évolution de la situation dans ce domaine depuis la publication 
de l’étude SCH1 (ii) ainsi que fournir une analyse poussée de certains problèmes, comme 
l’accès privilégié aux services médicaux, la vente abusive et les risques potentiels associés 
à une pratique double. 

L’étude a porté sur les 28 pays membres de l’UE, avec une attention toute particulière aux 
pays  suivants :  la  Grèce,  la  Croatie,  la  Hongrie,  la  Lituanie,  la  Pologne  et  la  Roumanie. 
L’analyse s’est basée sur une recherche documentaire, une étude en ligne envoyée aux 
acteurs européens, des entrevues thématiques avec de nombreuses organisations dans le 
secteur de la santé (UE) et des missions d’enquête, qui fournissent plus d’informations et 
des exemples sur les six pays en question. 

Les conclusions de l’étude ont été les suivantes : 

  La corruption dans la prestation de services médicaux demeure l’un des principaux 
enjeux, notamment au sein de nombreux pays membres de l’Europe du Sud et de 
l’Est.  

  Les États membres, qui ont une vision très claire de la corruption (dans le secteur 
de  la  santé),  sont  également  concernés  par  l’octroi  d’un  accès  privilégié  aux 
services  médicaux  ou par  les  risques  potentiels  associés à  la  pratique  double  qui 
sont liés à la corruption.  

  Les procédures transparentes sont des facteurs clés pour lutter contre la corruption 

lors des processus d’approvisionnement 

  Des tentatives de lutte contre la vente abusive sont de plus en plus nombreuses à 

la fois à l’échelle nationale et européenne  

2 SCH = étude sur la corruption dans le secteur de la santé  

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Updated Study on Corruption in the Healthcare Sector  

Executive Summary 

Introduction 

The  health  sector  is  one  of  the  areas  that  is  particularly  vulnerable  to  corruption,  but 
relatively little is known about this subject. In this context, the Commission (Directorate-
General Migration and Home Affairs – DG Home) commissioned Ecorys to conduct an initial 
study on corruption in the healthcare sector (henceforth: SCH1) in 2012. The objectives of 
the  SCH1  were  to  develop  a  better  understanding  of  the  extent,  nature,  and  impact  of 
corrupt practices in the healthcare sector across the EU, and to assess the capacity of the 
Member  States  to  prevent  and  control  corruption  within  the  healthcare  system  and  the 
effectiveness of such measures in practice.  

The study identified six typologies of corruption (see Figure 0.1): 

  bribery in medical service delivery; 
  procurement corruption; 
improper marketing relations; 
 
  misuse of (high) level positions; 
  undue reimbursement claims; 
 

fraud  and  embezzlement  of  medicines  and  medical  devices  (not  included  in 
figure 0.1). 

Figure 0.1 Corruption in the healthcare sector typologies 

Source: Ecorys, 2013. 

In 2016, the Commission requested an update (henceforth: SCH2) of the initial study. The 
purpose of the update study on corruption in the healthcare sector (SCH2) is two-fold: (i) 
to analyse and report on relevant developments since the publication of SCH1 and (ii) to 

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Updated Study on Corruption in the Healthcare Sector  

provide  an  in-depth  analysis  of  selected  issues:  privileged  access  to  medical  services, 
improper marketing, and potential risks involving double practice.  

The study covers all EU-28 Member States, with specific attention focused on six countries: 
Greece, Croatia, Hungary, Lithuania, Poland, and Romania. The analysis is based on desk 
research, an online survey sent to stakeholders across the EU, thematic interviews with 
various  organisations  and  associations  in  the  field  of  (EU)  healthcare,  and  fact-finding 
missions, providing more detailed analysis and examples with regard to the six selected 
countries. 

Corruption in general and corruption in healthcare are correlated 

The  Special  Eurobarometer  397  (published  in  February  2014)  shows  that  corruption  in 
healthcare is not an isolated phenomenon. In general, perceived corruption in healthcare 
is  correlated  with  general  levels  of  perceived  corruption.  Greece,  Lithuania,  Romania, 
Slovakia, and Cyprus are among the countries with both the highest levels of perceived 
general  corruption  and  specific  healthcare  corruption,  while  at  the  other  side  of  the 
continuum the Scandinavian countries score well on both indicators.  

Main corruption typologies highlighted 

Bribery in medical services delivery remains a challenge  

Bribery in medical service delivery remains one of the main challenges, especially in many 
Eastern and Southern European Member States. Countries where patients have the most 
frequent  experiences  of  paying  for  privileged  treatment  are:  Slovakia  (41%),  Slovenia 
(38%) and Germany, Spain, France and Sweden (all 29%), while the EU average stands 
at 19%. In-depth analysis of the Special Eurobarometer 397 on corruption in healthcare 
perceptions reveals that the perceptions of corruption in healthcare are not influenced by 
experiences in actually giving fees, i.e. an extra payment or a valuable gift to a nurse or a 
physician, or a donation to the hospital. 

Stakeholders mentioned that the root causes of this type of corruption, for most countries, 
include  a  general  acceptance  of  bribery;  low  wages  for  health  professionals,  including 
physicians;  ineffective  managerial  structures;  and  ineffective  control  mechanisms. 
Prosecution  of  physicians  for  bribery  in  medical  service  delivery  has,  over  the  last  few 
years,  become  more  common.  Also,  it  appears  that  the  younger  generation  –  both 
physicians and patients – tend to no longer accept bribery in medical service delivery as 
common practice.  

There are, however, differences between Member States in terms of their efforts as well 
as their successes, in fighting this type of corruption since the publication of the SCH1. For 
example, much progress was made in Poland as the result of a combination of awareness 
raising campaigns, active prosecution of physicians, and media coverage of these cases. 
In Greece, on the other hand, the situation has worsened due to the economic downturn.  

Privileged access and double practice is hidden across all EU Member States 

Compared to bribery in medical service delivery, corruption related to granting privileged 
access  to  healthcare  or  potential  risks  involving  double  practice  occur  much  more 
randomly. Analysis of the Special Eurobarometer 397 shows that the problem of double 
practice  is  not  isolated  to  Member  States  with  a  high  perception  of  corruption  (in 
healthcare); there is no clear correlation of experiences with double practice with general 
perceptions  of  corruption  in  the  healthcare  sector.  In  some  countries  misuse  of  double 
practice goes hand in hand with privileged access. Also, it was observed that in many of 
the countries, double practice is not illegal, and sometimes even considered a good thing 
as it may reduce informal payments and/or decrease waiting lists in the public sector. 

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Transparent procedures are key in addressing corruption in procurement processes 

One  of  the  proposed  solutions  to  mitigate  the  risks  for  this  type  of  corruption  is  the 
centralisation of procurement processes. An important precondition for this measure to be 
effective  is  transparency  in  the  central  procurement  body.  We  found  that  stakeholders 
differ in their views on whether or not centralising procurement will reduce corruption risk. 

Several Member States have implemented other measures to reduce the risk of corruption 
in the procurement of medical devices and pharmaceuticals, such as: the online publication 
of  procurement  data,  collaboration  (between  Member  States)  to  enable  larger 
procurements  and  to  reduce  the  bargaining  power  of  the  industry,  creation  of  anti-
corruption bureaus/directorates, and the development of a price observatory for medical 
supplies indicating the maximum prices that can be charged to hospitals.  

Attempts to address improper marketing increases at both EU and national level 

Relationships  between  physicians  and  the  industry  are  necessary  and  beneficial,  in  the 
context  of  product  development  and  monitoring  the  appropriate  use  of  medicines  in 
practice. However, these relationships also create risks for improper and corrupt practices, 
such as influencing prescribing behaviour.  

In some countries policies allowing physicians to prescribe only active substances instead 
of branded medications have had some effect. However, physicians may still find ways to 
prescribe branded products, and industry can shift their influencing efforts from physicians 
to the officials responsible for determining the reimbursement list. 

In  order  to  prevent  improper  marketing,  several  (self-)regulation  initiatives  have  been 
introduced,  both  at  the  EU  and  at  national  level.  The  trade  associations  EFPIA 
(pharmaceuticals)  and  MedTech  Europe  (medical  devices),  have  both  introduced  a  new 
code since the publication of the SCH1 in October 2013. In addition to the transposition of 
the EFPIA and MedTech Europe Code, there are also other initiatives at the national level 
to  prevent  improper  marketing.  In  many  countries,  the  national  associations  have 
introduced a code of conduct or ethics, or transparency enhancing initiatives. 

Revisiting the general conclusions of SCH1  

In the initial study on Corruption in the Healthcare Sector (SCH1), 13 general conclusions 
were drawn. In the current study, stakeholders were asked, during the survey, fact-finding 
missions  and  interviews,  whether  they  believe  these  conclusions  are  still  relevant.  The 
consulted stakeholders added the following nuances to the conclusions on the phenomena 
of corruption in healthcare, and avenues to combat it:  

Conclusion 1: Convictions of (high-profile) corruption cases have a deterrent and norm-
setting effect. 

The majority of the stakeholders confirmed that this conclusion is still valid. However, in 
some countries hardly any cases are brought to court and this weakens the norm-setting 
effect. In addition, stakeholders mentioned that a norm-setting effect is only effective when 
it is followed up by sustained political action.  

Conclusion 2: Centralisation of procurement is a method to lower the risks of corruption. 

The  majority  of  the  stakeholders  consulted  agreed  (either  fully  or  to  some  extent)  that 
central procurement is a good method of lowering the risks for corruption. Agreement with 
this  conclusion  is  stronger  in Eastern  and North  West  Europe  than  in the  Mediterranean 
countries. It was noted that it may also be important to have public registries in place and 

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to  introduce  transparency  increasing  measures,  otherwise  centralised  procurement  may 
actually face more risks (also see “conclusion 3”).  

Conclusion 3: Central procurement systems can become vulnerable as targets for lobbyists 
and more politically inspired types of corruption.  

The  majority  of  the  stakeholders  agreed  with  this  statement,  though  it  was  noted  that 
decentralised systems may also be prone to lobbying and politically inspired corruption. As 
with  conclusion  2,  for  conclusion  3  we  observed  regional  differences  in  the  stakeholder 
responses  in  the  survey:  the  outcomes  indicate  that  the  risks  of  lobbying  and  political 
inspired types of corruption are perceived to be higher in the Mediterranean and Eastern 
Europe area compared to North West Europe. 

Conclusion 4: Bribery in medical service delivery cannot be contested with only targeted 
policies against the phenomenon as such, but need to be supplemented with a variety of 
accompanying (structural) measures.  

In regions where bribery in medical service delivery is still common, the majority of the 
stakeholders agreed that both targeted policies and structural measures are required to 
fight  this  problem.  Interviewees  indicated  a  wide  variety  of  requisite  accompanying 
measures, including: strengthening the judicial system, changes in the healthcare system, 
and changes in attitudes towards corrupt practices. In North West Europe, where this form 
of corruption is less common, only a minority of the stakeholders expressed the need for 
more structural changes alongside targeted policies.  

Conclusion  5:  Raising  salaries  does  not  have  a  significant  preventive  effect  on  reducing 
bribery in medical service delivery. 

Low salaries are indeed a problem, according to the majority of the stakeholders. However, 
the majority of respondents in all regions agree that raising salaries cannot be a standalone 
measure. For example, it was mentioned that active prosecution and public awareness of 
the unethical aspects are also needed. 

Conclusion 6: There is more than one root cause of corruption in healthcare.  

Survey  results  showed  that  the  most  frequently  mentioned  root  causes  are:  a  general 
acceptance  of  corruption,  ineffective  managerial  structures,  inappropriate  financing 
mechanisms, and unequal allocation of resources. Respondents also mentioned insufficient 
healthcare  capacity  and  insufficient  funding  for  independent  medical  research  as  causes 
for corruption. 

Conclusion 7: The introduction of transparent waiting lists has a positive effect on reducing 
healthcare bribery. 

Most stakeholders agreed that introducing transparent waiting lists would have a positive 
effect on healthcare bribery. However, recent attempts to reduce such lists has not been 
successful in all countries, for example, due to the fact that the lists were not frequently 
updated, which led to outdated information to patients.  

Conclusion 8: Prescription of generics instead of branded pharmaceutical products has a 
positive effect on reducing healthcare bribery. 

The majority of respondents indicated that they are of the opinion that the prescription of 
generics instead of branded pharmaceutical has, at least to some extent, a positive effect 
on  reducing  healthcare  bribery.  Particularly  in  Eastern  Europe,  where  several  countries 
have  introduced  this  type  of  policy,  the  majority  of  people  agree  to  the  statement. 
However, our research has shown that in practice, this measure has had a minimal impact 
to date, or only reduces bribery to some extent.  

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Conclusion 9: Self-regulation between the industry and healthcare providers is needed to 
fight corruption in healthcare. 

The  vast  majority  of  stakeholders  agreed  that  self-regulation  is  an  instrument  to  fight 
corruption.  Looking  at  the  different  regions,  it  is  clear  that  stakeholders  in  Eastern 
European countries appear to be the most sceptical, and only expect self-regulation to be 
effective to ‘some extent’. Many stakeholders noted that self-regulation is important, but 
insufficient on its own, and that it would be beneficial if initiatives between the industry 
and  the  healthcare  provider  were  embedded  in  legislation,  for  example,  to  strengthen 
enforcement mechanisms.  

Conclusion 10: Self-regulation among players (such as within the pharmaceutical industry 
or among physicians) is needed to fight corruption in healthcare. 

The majority of the stakeholders agreed that self-regulation among players is important. 
Compared to ‘conclusion 9’ there is relatively little geographical variation in the responses 
of  stakeholders.  As  with  self-regulation  between  the  industry  and  healthcare  providers 
(conclusion 9), stakeholders note that it is not sufficient by itself, and that incentives for 
cooperation are important for self-regulation to be effective.  

Conclusion 11: Awareness raising campaigns and fraud and corruption reporting hotlines 
are an effective instrument to fight corruption in healthcare. 

Most stakeholders agreed that awareness campaigns and reporting hotlines are effective 
instruments in the fight against corruption. Nevertheless, some interviewees stressed that 
many  patients  do  not  report  to  such  hotlines,  and  therefore  many  cases  may  remain 
unknown. Also, reporting hotlines alone cannot be effective in reducing corruption; they 
need to be combined with other measures as well as legislation.  

Conclusion 12: The government should play a (more) active role in creating transparency 
in the relations between the industry and healthcare providers. 

According to the vast majority of the stakeholders, the government should play a (more) 
active  role  in  creating  transparency  in  the  relations  between  industry  and  healthcare 
providers. The respondents in North West Europe are the most positive about the role the 
government  could  play  in  this.  In  our  research,  we  encountered  incidental  scepticism 
regarding the role of the government when governments do not show sufficient willingness 
to fight corruption in general.  

Conclusion 13: Active – independent – media involvement and pressure from ‘civil society’ 
watchdogs are essential to fight corruption in healthcare. 

Media  involvement  and  civil  pressure  are  generally  considered  as  essential  to  fight 
corruption, also by the stakeholders involved in this study: the vast majority agreed with 
the  statement  at  least  to some  extent. Though it  is  considered  an  important tool  in  the 
fight against corruption, our research shows that there is a difference between countries 
regarding the countervailing power of these ‘watchdogs’. 

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RESUME ANALYTIQUE 

Présentation 

La santé est l’un des secteurs qui est particulièrement vulnérable à la corruption, mais sur 
lequel on en sait relativement peu. Dans ce contexte, la Commission (Direction générale 
pour les migrations et les affaires intérieures – DG Affaires intérieures) a chargé Ecorys de 
mener  une première  enquête  sur la  corruption  dans  le  secteur  de  la  santé  (désormais : 
SCH1) en 2012. L’étude SCH1 visait à comprendre mieux l’impact, le caractère et l’étendue 
des  pratiques  de  corruption  dans  le  secteur  de  la  santé  au  sein  de  l’UE,  et  d’évaluer  la 
capacité des États membres à empêcher et contrôler la corruption au sein de leur système 
de santé ainsi que l’efficacité de ces mesures dans la pratique.  

L’étude a permis d’identifier six types de corruption (se référer au Schéma 0.1) : 

corruption dans la prestation de services médicaux ; 
corruption dans l’approvisionnement ; 

 
 
  mauvaises relations commerciales ; 
 
  demandes de remboursement indu ; 
 

recours abusif aux fonctions de (haut) niveau ; 

fraude et détournement de médicaments et de dispositifs médicaux. 

Schéma 0.1  Types de corruption dans le secteur de la santé 

Source : Ecorys, 2013. 

En 2016, la Commission a demandé une mise à jour de la première étude (désormais : 
SCH2). L’étude sur la corruption dans le secteur de la santé mise à jour (SCH2) visait 2 

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objectifs : (I) Analyser et faire état de l’évolution de la situation dans ce domaine depuis 
la publication de l’étude SCH1 (ii) et fournir une analyse poussée de certains problèmes, 
comme l’accès privilégié aux services médicaux, la vente abusive et les risques potentiels 
associés à une pratique double.  

L’étude porte sur les 28 pays membres de l’UE, avec une attention toute particulière aux 
6 pays suivants : la Grèce, la Croatie, la Hongrie, la Lituanie, la Pologne et la Roumanie. 
L’analyse s’est basée sur une recherche documentaire, une étude en ligne envoyée aux 
acteurs  européens,  des  entrevues  thématiques  avec  de  nombreuses  organisations  et 
associations dans le secteur de la santé (UE) et des missions d’enquête, qui fournissent 
plus d’informations et des exemples sur les six pays en question. 

La  corruption  de  manière  générale  et  la  corruption  dans  le  secteur  de  la  santé 
sont liées 

L’Eurobaromètre  spécial  397  (publié  en  février  2014)  indique  que  la  corruption  dans  le 
secteur  de  la  santé  n’est  pas  un  phénomène  isolé.  D’une  façon  générale,  la  corruption 
perçue dans le secteur de la santé est liée à la corruption perçue à l’échelle globale. La 
Grèce, la Lituanie, la Roumanie, la Slovaquie et Chypre font partie des pays qui disposent 
à la fois des niveaux les plus élevés de corruption perçue à l’échelle globale, et notamment 
dans le secteur de la santé, alors qu’à l’autre extrémité, les pays scandinaves obtiennent 
de bons résultats concernant ces 2 indicateurs.  

Principaux types de corruption mis en avant 

La corruption dans la prestation de services médicaux demeure un enjeu 

La corruption dans la prestation de services médicaux demeure l’un des principaux enjeux, 
notamment au sein de nombreux pays membres de l’Europe du Sud et de l’Est. Les pays 
dont les patients ont le plus l’habitude de payer pour obtenir des soins privilégiés sont : la 
Slovaquie  (41 %),  la  Slovénie  (38 %)  et  l’Allemagne,  l’Espagne,  la  France  et  la  Suède 
(29 % au total), alors que la moyenne européenne s’élève à 19 %. L’analyse poussée de 
l’Eurobaromètre spécial 397 en matière de corruption perçue dans le secteur de la santé 
révèle  que  la  pratique  d’honoraires  accordés  actuellement,  comme  un  remboursement 
supplémentaire ou un cadeau de valeur à une infirmière ou à un médecin, ou bien un don 
à l’hôpital, n’influe pas sur les perceptions de la corruption dans le secteur de la santé. 

Les  acteurs  ont  indiqué  que  les  causes  pour  la  plupart  des  pays  viennent  de  la 
reconnaissance  de  la  corruption  d’une  manière  générale,  des  faibles  revenus  des 
professionnels de la santé, y compris les médecins; ainsi que de l’inefficacité des structures 
de  gestion  et  des  mécanismes  de  contrôle.  Poursuivre  en  justice  des  médecins  pour 
corruption  dans  la  prestation  de  services  médicaux  est  devenu,  au  cours  des  dernières 
années, de plus en plus courant. Par ailleurs, la nouvelle génération, à la fois les médecins 
et les patients, semble ne plus reconnaître que la corruption dans la prestation de services 
médicaux est une pratique courante.  

Néanmoins, depuis la publication de l’étude SCH1, les États membres semblent fournir des 
efforts de degré différent et progresser de manière distincte en termes de lutte contre ce 
type de corruption. Ainsi, de nombreuses avancées ont été réalisées en Pologne suite à la 
combinaison de campagnes de sensibilisation, de poursuites engagées contre des médecins 
et de couverture médiatique de ces procès. De l’autre côté, en Grèce, la situation a empiré 
en raison de la récession économique.  

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L’accès  privilégié  et  la  pratique  double  sont  dissimulés  parmi  l’ensemble  des  États 
membres de l’UE 

Comparée  à  la  corruption  dans  la  prestation  de  services  médicaux,  la  corruption  liée  à 
l’octroi d’un accès privilégié aux soins de santé ou les risques potentiels associés à une 
pratique double surviennent davantage de manière aléatoire. L’analyse de l’Eurobaromètre 
spécial 397 indique que le problème de la pratique double ne concerne pas seulement les 
États  membres  à  la  perception  élevée  en  matière  de  corruption  (dans  le  secteur  de  la 
santé).  La  pratique  double  et  les  perceptions  globales  en  matière  de  corruption  dans  le 
secteur de la santé ne sont, de toute évidence, aucunement liées. Dans certains pays, le 
recours abusif à la pratique double va de pair avec l’accès privilégié. On a également fait 
valoir que dans de nombreux pays, la pratique double n’est pas un acte illégal, et qu’elle 
est même parfois considérée comme une bonne chose, car elle peut réduire les paiements 
informels et/ou les listes d’attente dans le secteur public. 

Les procédures transparentes sont des facteurs clés dans la lutte contre la corruption lors 
des processus d’approvisionnement 

L’une des solutions proposées pour diminuer les risques de ce type de corruption est la 
centralisation des processus d’approvisionnement. La transparence du système centralisé 
des approvisionnements fait partie des conditions préalables importantes pour que cette 
mesure soit efficace. Nous avons constaté que les opinions des acteurs divergent quant au 
fait de savoir si centraliser ou pas les achats réduirait le risque de corruption. 

Certains États membres ont mis en place d’autres mesures afin de diminuer le risque de 
corruption au cours de l’achat de dispositifs médicaux et produits pharmaceutiques, telles 
que : la publication en ligne de données relatives aux achats, la collaboration (entre les 
États membres) afin de permettre des volumes d’approvisionnement plus importants et de 
réduire la possibilité de négocier dans le secteur, la création de bureaux/directions chargés 
de lutter contre la corruption ainsi que d’un observatoire des prix des fournitures médicales 
qui indiquerait les prix maximums qui peuvent être facturés aux hôpitaux.  

Des tentatives de lutte contre la vente abusive sont de plus en plus nombreuses à la fois 
à l’échelle nationale et européenne 

Les relations entre les médecins et l’industrie sont nécessaires et bénéfiques dans le cadre 
d’un  développement  de  produits  et  d’un  contrôle  de  l’utilisation  appropriée  de 
médicaments dans la pratique. Cependant, ces relations génèrent également des risques 
de  pratiques  abusives  et  actes  de  corruption,  comme  influencer  le  comportement  du 
prescripteur.  

Dans  certains  pays,  les  politiques  permettant  les  médecins  de  ne  prescrire  que  des 
substances actives à la place de médicaments de marque ont en quelque sorte contribué 
à  lutter  contre  la  corruption.  Cependant,  les  médecins  peuvent  toujours  trouver  des 
moyens  pour  prescrire  des  produits  de  marque.  Par  ailleurs,  au  lieu  de  s’efforcer  à 
influencer les médecins, le secteur peut influencer les représentants chargés d’établir la 
liste des remboursements. 

Afin  d’empêcher  la  vente  abusive,  plusieurs  mesures  d’(auto)réglementation  ont  été 
présentées.  À  l’échelle  européenne  et  nationale.  Les associations  professionnelles  EFPIA 
(produits pharmaceutiques) et MedTech Europe (dispositifs médicaux) ont lancé toutes les 
2  un  nouveau  code  depuis  la  publication  de  l’étude  SCH1  en  octobre  2013.  Outre  la 
transposition du code de l’EFPIA et de la MedTech, d’autres mesures sur le plan national 
permettent  également  d’empêcher  la  vente  abusive.  Dans  de  nombreux  pays,  les 
associations  nationales  ont  lancé  un  code  de  conduite,  d’éthique  ou  de  transparence 
encourageant la prise d’initiatives. 

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Updated Study on Corruption in the Healthcare Sector  

Conclusions générales de SCH1 

Dans la première étude sur la Corruption dans le secteur de la santé (SCH1), 13 
conclusions générales ont été tirées. Dans l’étude actuelle, il a été demandé aux acteurs, 
au cours de l’étude, des missions d’enquête et des entrevues, s’ils estiment que ces 
conclusions demeurent pertinentes. Les acteurs interrogés ont ajouté les nuances 
suivantes aux conclusions à propos du phénomène de corruption dans le secteur de la 
santé proprement dit et aux possibilités pour lutter contre :   

Conclusion 1 : Les condamnations pour affaires de corruption (médiatiques) ont un impact 
dissuasif et normatif. 

La  majorité  des  acteurs  a  confirmé  que  cette  conclusion  est  toujours  d’actualité. 
Cependant,  dans  certains  pays,  rares  sont  les  affaires  qui  sont  portées  devant  les 
tribunaux, ce qui tend à réduire l’effet normatif. En outre, les acteurs ont indiqué qu’un 
effet normatif n’est efficace que s’il est suivi par l’appui d’actions politiques.  

Conclusion  2 :  La  centralisation  des  achats  est  un  moyen  de  diminuer  les  risques  de 
corruption. 

La majorité des acteurs interrogés se sont entendus (soit totalement soit dans une certaine 
mesure)  sur  le  fait  que  l’approvisionnement  centralisé  est  un  bon  moyen  de  réduire  les 
risques  de  corruption.  L’Europe  du  Nord-Ouest  et  de  l’Est  est  plus  d’accord  avec  cette 
conclusion que les pays méditerranéens. 

Il convenait de noter qu’il est peut-être également important de disposer de registres 
publics et de mettre en place des mesures dans le but d’obtenir plus de transparence, car 
sinon il est possible que l’approvisionnement centralisé soit effectivement confronté à 
plus de risques (se référer également à la « conclusion 3. »)   

Conclusion  3 :  Les  systèmes  d’approvisionnement  centralisés  peuvent  devenir  une  cible 
vulnérable pour les lobbyistes et les politiques qui encouragent ces types de corruption.  

La majorité des acteurs se sont entendus sur cette déclaration, bien qu’il a été convenu 
que  les  systèmes  décentralisés  peuvent  également  faire  l’objet  d’une  corruption 
encouragée  par  des  lobbyistes  et  politiques.  Comme  avec  la  conclusion  2,  pour  la 
conclusion 3 nous avons noté des différences au niveau des régions dans les réponses des 
acteurs  de  l’étude.  Les  résultats  indiquent  notamment  que  les  risques  de  types  de 
corruption encouragés par des lobbyistes et des politiques sont perçus comme étant plus 
élevés  en  Europe  de  l’Est  que  dans  les  pays  méditerranéens  par  rapport  à  l’Europe  du 
Nord-Ouest. 

Conclusion  4 :  Des  politiques  ciblées  ne  suffisent  pas  à  lutter  contre  le  phénomène  de 
corruption dans la prestation de services médicaux à proprement parler. D’autres mesures 
d’accompagnement (structurelles) doivent également être prises.  

Dans les régions où la corruption dans la prestation de services médicaux demeure une 
pratique courante, la majorité des acteurs se sont entendus sur le fait que des politiques 
ciblées ainsi que des mesures structurelles doivent être mises en place pour lutter contre 
ce problème. Les acteurs interrogés ont indiqué que les mesures d’accompagnement qui 
doivent  être  prises  sont  multiples.  Il  s’agit  du  renforcement  du  système  judiciaire,  des 
modifications du système de la santé et des changements de comportement vis-à-vis des 
pratiques  en  matière  de  corruption.    En  Europe  du  Nord-Ouest,  là  où  cette  forme  de 
corruption est moins courante, seule une minorité des acteurs a exprimé le besoin de plus 
amples changements structurels à l’image des politiques ciblées.  

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Updated Study on Corruption in the Healthcare Sector  

Conclusion  5 :  L’augmentation  des  salaires  n’a  pas  d’effet  préventif  important  sur  la 
réduction de la corruption dans la prestation de services médicaux. 

La majorité des acteurs estime que les bas salaires représentent bel et bien un problème. 
Néanmoins, la majorité des acteurs interrogés dans toutes les régions sont d’accord sur le 
fait qu’augmenter les salaires ne peut pas faire l’objet d’une mesure isolée. Ainsi, il a été 
indiqué que les poursuites engagées et la sensibilisation des citoyens quant aux aspects 
contraires à l’éthique sont également nécessaires. 

Conclusion  6 :  Les  causes  principales  de  corruption  dans  le  secteur  de  la  santé  sont 
multiples.  

Les résultats de l’étude ont révélé que les origines des causes qui sont mentionnées le plus 
souvent sont : une reconnaissance de la corruption en général, l’inefficacité des structures 
de gestion, des mécanismes de financement inappropriés et une distribution inégale des 
ressources. Les acteurs interrogés ont également indiqué que les moyens insuffisants dans 
le  secteur  de  la  santé  et  le  manque  de  financement  pour  la  recherche  médicale 
indépendante sont à l’origine de la corruption. 

Conclusion 7 : La mise en place de listes d’attente transparentes joue un rôle clé dans la 
diminution de la corruption dans le secteur de la santé. 

La plupart des acteurs se sont entendus sur le fait que mettre en place des listes d’attente 
transparentes contribuerait réellement à la diminution de la corruption dans le secteur de 
la santé. Néanmoins, les dernières tentatives de réduire ces listes n’a pas porté ses fruits 
dans tous les pays, par exemple du fait que les listes n’ont pas été souvent mises à jour, 
d’où des informations désuètes pour les patients.  

Conclusion 8 :  La prescription  de génériques à  la  place  de  produits pharmaceutiques  de 
marque a permis de diminuer la corruption dans le secteur de la santé. 

La  majorité  des  acteurs  interrogés  ont  indiqué  qu’ils  estiment  que  la  prescription  de 
génériques à la place de produits pharmaceutiques de marque contribue, du moins dans 
une certaine mesure, à réduire la corruption dans le secteur de la santé. Notamment en 
Europe de l’Est, où plusieurs pays ont mis en place ce type de politique, et où la majorité 
des  citoyens  sont  d’accord  avec  cette  déclaration.  Cependant,  notre  étude  a  révélé  que 
dans la pratique, cette mesure a eu très peu d’incidence jusqu’à présent ou ne diminue la 
corruption que jusqu’à un certain point.  

Conclusion  9 :  L’autoréglementation  entre  l’industrie  et  les  prestataires  de  santé  est 
nécessaire pour lutter contre la corruption dans le secteur de la santé. 

La grande majorité des acteurs se sont accordés sur le fait que l’autoréglementation est 
un  moyen  de  lutter  contre  la  corruption.  Si  l’on  examine  les  différentes  régions,  on 
remarque que les acteurs des pays de l’Europe de l’Est semblent être plus sceptiques et 
ne  s’attendent  à  ce  que  l’autoréglementation  ne  soit  efficace  que  jusqu’à  « un  certain 
point. »  De  nombreux  acteurs  ont  remarqué  que  l’autoréglementation  est  une  mesure 
importante, mais pas suffisante. Par ailleurs, elle serait plus bénéfique si les mesures prises 
entre  l’industrie  et  les  prestataires  de  santé  étaient  inscrites  dans  la  législation,  par 
exemple pour renforcer les mécanismes de contrôle.   

Conclusion  10 :  L’autoréglementation  parmi  les  acteurs  (tels  qu’au  sein  de  l’industrie 
pharmaceutique ou parmi les médecins) est requise pour lutter contre la corruption dans 
le secteur de la santé. 

La majorité des acteurs se sont entendus sur le fait que l’autoréglementation parmi eux 
est une mesure importante. Par rapport à la « conclusion 9 », la réponse des acteurs varie 
relativement peu selon les régions. Comme avec l’autoréglementation entre l’industrie et 

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les prestataires de santé (conclusion 9), les acteurs remarquent que seule elle n’est pas 
suffisante, et que les incitations à la coopération constituent un élément important pour 
que l’autoréglementation devienne efficace.  

Conclusion 11 : Les campagnes de sensibilisation, l’assistance téléphonique pour signaler 
des  actes  de  fraude  ou  de  corruption  sont  des  moyens  efficaces  pour  lutter  contre  la 
corruption dans le secteur de la santé. 

La plupart des acteurs se sont accordés sur le fait que les campagnes de sensibilisation et 
l’assistance téléphonique pour faire un signalement sont des moyens efficaces dans la lutte 
contre la corruption. Néanmoins, certains acteurs interrogés ont souligné que de nombreux 
patients n’ont pas recours à cette assistance téléphonique. Par conséquent, de nombreuses 
affaires  pourront  ne  pas  être  connues.  En  outre,  recourir  à  l’assistance  téléphonique  ne 
peut pas être le seul moyen efficace pour diminuer la corruption ; cette action doit être 
combinée à d’autres mesures et lois pour lutter contre la corruption.  

Conclusion 12 : Le gouvernement devra prendre (davantage) de mesures pour rendre les 
relations transparentes entre l’industrie et les prestataires de santé. 

Selon,  la  grande  majorité  des  acteurs,  le  gouvernement  devra  prendre  (davantage)  de 
mesures  pour  rendre  les  relations  transparences  entre  l’industrie  et  les  prestataires  de 
santé.  Les  acteurs  interrogés  en  Europe  du  Nord-Ouest  sont  ceux  qui  sont  les  plus 
favorables quant à une contribution du gouvernement dans cette lutte.  Dans notre étude, 
nous nous sommes retrouvés face à un scepticisme lié au rôle du gouvernement lorsque 
les gouvernements n’affichent pas une volonté suffisante pour lutter contre la corruption 
d’une manière générale.  

Conclusion  13 :  L’importance  de  la  participation  des  médias  de  manière  isolée  et  active 
ainsi  que  la  pression  des  organismes  de  surveillance  de  la  « société  civile »  est 
indispensable pour lutter contre la corruption dans le secteur de la santé. 

En général, la participation des médias et la pression de la société civile sont considérées 
comme  essentielles  pour  lutter  contre  la  corruption,  également  par  les  acteurs  qui  ont 
participé à cette étude. La grande majorité d’entre eux s’est entendue sur la déclaration, 
du moins dans une certaine mesure. Bien qu’elle soit considérée comme un outil important 
dans  la  lutte  contre  la  corruption,  notre  étude  montre  que  le  contrepoids  de  ces 
« organismes de surveillance » varie selon les pays. 

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Updated Study on Corruption in the Healthcare Sector  

1.  INTRODUCTION 

1.1.  Background of the study 
The fight against corruption is one of the key priorities for the European Commission. In 
2011,  an  anti-corruption  package  was  adopted  to  reinforce  European  Union  (EU)  policy 
against corruption. In 2014, the first EU Anti-Corruption report was published, analysing 
the efforts of Member States against corruption.3  

The  health  sector  is  one  of  the  areas  that  is  particularly  vulnerable  to  corruption,  but 
relatively little is known about this subject. In this context, the Commission (Directorate-
General Migration and Home Affairs – DG Home) commissioned Ecorys to conduct an initial 
study on corruption in the healthcare sector (henceforth: SCH1) in 2012. The objectives of 
the  SCH1  were  to  develop  a  better  understanding  of  the  extent,  nature  and  impact  of 
corrupt practices in the healthcare sector across the EU, and to assess the capacity of the 
Member  States  to  prevent  and  control  corruption  within  the  healthcare  system  and  the 
effectiveness  of  such  measures  in  practice.  We  focused  on  medical  service  delivery, 
procurement  and  certification  of  medical  devices,  and  procurement  and  authorisation  of 
pharmaceuticals. 

In the SCH1 we identified six typologies of corruption in the selected healthcare areas on 
the basis of desk research and more than 100 interviews, as well as an analysis of 86 cases 
of corruption (see Figure 1.1): 

  bribery in medical service delivery; 
  procurement corruption; 
improper marketing relations; 
 
  misuse of (high) level positions; 
  undue reimbursement claims; 
 

fraud  and  embezzlement  of  medicines  and  medical  devices  (not  included  in 
Figure 1.1). 

The latter two typologies were outside the scope of the study.  

3 COM(2014) 38 final - EU anti-corruption report.  

21 

 
 
 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

Figure 1.1 Corruption in the healthcare sector typologies 

Source: Ecorys, 2013. 

Furthermore, we identified three categories of policies and practices to prevent and control 
corruption:  

  generic  anti-corruption  policies  and  practices,  e.g.  procurement  policies  and 

forceful anti-bribery legislation;  

  generic  healthcare  policies  and  practices,  e.g.  healthcare  supervision  and 

 

reforms to address structural healthcare system weaknesses; and  
corruption-in-health policies, e.g. health specific anti-corruption strategies and 
self-regulation.  

We concluded that corruption in the healthcare sector occurs in all EU Member States, and 
that both the nature and the prevalence of corruption typologies differ across the EU. In 
addition, we found no single policy to successfully fight corruption in healthcare. Policies and 
practices  that  work  in  one  country  do  not  necessarily  work  in  another.  Necessary 
preconditions for successfully targeting corruption in health care policies included:  

  a general rejection of corruption by society;  
 
 
 

clear and effectively enforced general anti-corruption legislation; 
independent and effective judicial follow up on corruption cases; and  
sound general procurement systems.  

1.2.  Scope and objectives of the study 
In 2016, the Commission requested an update (henceforth: SCH2) of the initial study.  

The purpose of this updated study on corruption in the healthcare sector is two-fold: 

I.  To  analyse  and  report  on  relevant  developments  since  the  publication  of  the  initial 

study on corruption in the healthcare sector (SCH1) (October 2013); 

II.  To provide an in-depth analysis of selected issues, including: 

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Updated Study on Corruption in the Healthcare Sector  

-  Privileged access to medical services (including not only informal payments but also 

the use of privileged information and information peddling);  

-  Improper  marketing  by  pharmaceutical  companies  and  medical  device  producers 
(at national and/or EU level, including for market authorisation and reimbursement 
approval); 

-  Potential risks involving double practice in public and private clinics. 

The  study  covers  all  EU-28  Member  States  with  specific  attention  (fact-finding  missions 
with  more  detailed  analysis  and  examples)  focused  on  six  countries:  Greece,  Croatia, 
Hungary,  Lithuania,  Poland,  and  Romania.  These  are  countries  where  the  EU  Anti-
Corruption Report highlights healthcare as an issue. 

In this study, we have - as in the initial study - : 

  Focused on practical aspects and kept the theoretical part to a minimum;  
  Not limited the scope to issues that are comparable across the EU; and 
  Focused on the specifics of each Member State and on illustrative case studies.  

This resulted in: 

  An  analysis  of  the  extent,  nature  and  impact  of  corrupt  practices  in  the 

healthcare sector across the EU; 

  An  analysis  of  the  capacity  of  the  Member  States  to  prevent  and  control 

healthcare corruption; and 

  Policy recommendations for further action, which could be beneficial at Member 

State and EU level. 

1.3.  General approach 
This study covers three – interlinked – components: 
1.  An update of the initial study; 
2.  Analysis of selected thematic issues; 
3.  Country studies.  

As  presented  in  the  Figure  below,  the  three  components  are  partially  overlapping  and 
therefore  certain  methods  (e.g.  survey  and  interviews)  were  used  to  collect  data  for 
multiple components.  

Figure 1.2 Overlap of the three research components 

23 

 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Component 1. Update of the initial study since October 2013 

Component 1 concerns an update of the initial study, covering all EU-28 Member States. 
We  sent  a  survey  to  relevant  stakeholders  in  all  EU-28  Member  States,  and  conducted 
interviews with stakeholders at the EU level. The stakeholders were asked if the findings 
and conclusions of the 2013 report are still relevant and what has changed (for example 
in  terms  of  occurrence/extent/legal  initiatives/policy  changes)  since  its  publication  in 
October 2013.  

Component 2. Thematic analysis 

We conducted desk research per thematic issue: 

  Privileged access to medical services (including informal payments and the use 

 

of privileged information and information peddling);  
Improper  marketing  by  pharmaceutical  companies  and  medical  device 
producers (at national and/or EU level, including for market authorisation and 
reimbursement approval); 

  Potential risks involving double practice in public and private clinics.  

Furthermore,  we  collected  data  through  the  survey  sent  to  stakeholders  in  all  EU-28 
Member  States  and  through  the  interviews  with  stakeholders  at  the  EU  level  (see 
component 1).  

Component 3. Country studies 

We  conducted  fact-finding  missions  in  all  selected  countries  (Greece,  Croatia,  Hungary, 
Lithuania, Poland, and Romania), which included interviews with relevant stakeholders in 
each country. In Chapter 2, we present our methodological approach in more detail. 

1.4.  Outline of the Final Report 
The report includes our methodology used (Chapter 2). Thereafter, we present the findings 
and conclusions of the study as follows:  

  Chapter 3 provides the results of the fact-finding missions to Greece, Croatia, 

Lithuania, Hungary, Poland and Romania (i.e. country reports); 

  Chapter 4 provides an update of the SCH1 study and an in-depth analysis of the 

selected thematic issues; 

  Chapter 5 presents our conclusions and recommendations;  
  The report is supported by the following Annexes: 
-  The interview guide; 
-  Overview of stakeholders invited for the survey; 
-  The survey design; and 
-  Corruption indicators (Special Eurobarometer 397). 

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Updated Study on Corruption in the Healthcare Sector  

2.  METHODOLOGICAL APPROACH 

As  stated  in  Chapter  1,  we  used  several  data  collection  tools,  including  desk  research, 
online  survey,  interviews,  and  fact-finding  missions.  In  the  sections  below,  we  provide 
more information on these tools. 

2.1.  Survey 
The purpose of the EU-28 Member States survey was two-fold: 
1.  To update the results of the initial study; and 
2.  To collect information on the thematic issues.  

The survey design and circulation was organised as follows: 

First, we compiled the list of survey invitees. Based on the initial study and desk research 
we gathered contact details from all relevant stakeholder categories (i.e. patients, payers, 
providers, industry and regulators), in all EU-28 Member States. 

The next step was to draft the survey.  

After agreement by DG Home, the survey was piloted by the EHFCN. The final version was 
programmed  in  Check  Market  (see  Annex  III).  The  survey  was  then  circulated  to  300 
invitees on 8 December 2016. A first reminder was sent out on 20 December 2016 and 
second reminder was sent out on 16 January 2017. The survey was closed at the end of 
January 2017.  

2.1.1.  Survey invitees 
The geographic spread of the 300 invitees is presented in Table 2.1, while the number of 
invitees per stakeholder category is presented in Table 2.2. 

Table 2.1 Overview number of surveys sent per Member State 

Country  

Number of surveys sent   Country  

Number of surveys 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czech Republic 

Denmark 

Estonia 

Finland 

France 

Germany 

Hungary 

Ireland 

Italy 

Grand total 

11 

20 

14 

3 

5 

11 

12 

7 

13 

20 

35 

1 

11 

13 

sent  

5 

7 

8 

8 

16 

9 

12 

9 

8 

7 

12 

20 

3 

300 

Latvia 

Lithuania 

Luxembourg 

Malta 

Netherlands 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

UK 

EU level  

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Table 2.2 Number of invitees by stakeholder category 

Stakeholder category 

Number of survey invitees 

Patients  

Payers  

Providers  

Industry  

Regulators  

Other  

Grand total 

46 

53 

74 

56 

58 

13 

300 

For more detailed lists of survey invitees per country, please see Annex II.  

2.1.2.  Response rate 
Out of 300 invitees, 44 responses were received, distributed geographically as presented 
in the Table below. This translates into a response rate of 14.7%, which is fairly common 
for online surveys. 

Table 2.3 Overview number of survey responses per Member State 

Country  

Number of survey responses  Country  

Number of survey 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

4 

2 

2 

1 

0 

Czech Republic  1 

Denmark 

Estonia 

Finland 

France 

Germany 

Hungary 

Ireland 

Italy 

Grand total 

2 

2 

2 

1 

2 

0 

0 

1 

responses 

Latvia 

Lithuania 

2 

3 

Luxembourg  0 

Malta 

0 

Netherlands  2 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

UK 

EU level  

7 

5 

1 

1 

1 

0 

3 

- 

44 

2.2.  Thematic interviews 
As  part  of  the  study,  we  conducted  thematic  interviews  with  various  organisations  and 
associations in the field of (EU) healthcare. The aim of these interviews was two-fold:  

  Discuss developments per thematic area since the initial study (extent, cases as 

well as good practices); and  
Identify current challenges with regard to the thematic areas: 

 
1.  Informal payments in medical service delivery; 
2.  Certification and procurement of medical devices; 
3.  Authorisation and procurement of pharmaceuticals; 
4.  Privileged access to medical services (including not only informal payments but 

also the use of privileged information and information peddling);  

5.  Improper marketing by pharmaceutical companies and medical device producers 
for  market  authorisation  and 

including 

level, 

(at  national  and/or  EU 
reimbursement approval); 

26 

 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

6.  Potential risks involving double practice in public and private clinics. 

Interviewees were approached in relation to specific themes as represented in the Figure 
below. 

Figure 2.1 Relevant stakeholder categories per thematic area 

Table  2.4  lists  the  organisations  that  we  approached  for  interviews  in  relation  to  the 
thematic areas. 

Table 2.4 Overview of organisations and persons invited for an interview 

Stakeholder 

Organisation 

Thematic area 

category 

Patients 

Payers 

European Patient Forum (EPF) 

International Association of Mutual Benefit 

1, 4 and 6 

1, 5 and 6 

Societies (AIM) 

Providers 

European Hospital and Healthcare Federation 

1, 2, 4, 5 and 6 

(HOPE) 

Standing Committee of European Doctors (CPME) 

European Union of General Practitioners / Family 

Physicians (UEMO) 

Industry 

MedTech Europe 

2 and 5 

European Federation of Pharmaceutical Industries 

3 and 5 

and Associations (EFPIA) 

Regulators 

Directorate-General Health and Food Safety (DG 

3 and 5 

SANTE) 

Directorate-General for Internal Market, Industry, 

2 and 5 

Entrepreneurship and SMEs (DG Growth) 

DG Home 

European Medicines Agency (EMA) 

Other 

Eurojust 

Transparency International 

All areas 

3 and 5 

All areas 

All areas 

European Association of Notified Bodies for Medical 

2 

Device (Team NB) 

EU research project: Assessment of patient 

1 

payment policies and projection of their efficiency, 
equity and quality effects (ASSPRO)4 

Reminders  were  sent  within  approximately  two  weeks  after  the  initial  request  for  an 
interview. Out of this group, representatives from the following organisations agreed to an 
interview: 

  AIM; 
  ASSPRO; 

4 See https://ec.europa.eu/research/social-sciences/pdf/project_synopses/ssh_projects_7-13.pdf, p.430. 

27 

 
 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

  DG Growth; 
  DG SANTE; 
  EMA; 
  EPF; 
  HOPE; 
  MedTech Europe; 
  Transparency International. 

Several of the organisations approached did not respond to the request for interview (e.g. 
EFPIA and Team NB), while others indicated that they were not willing to contribute to the 
study (e.g. CPME).  

Prior to the interview, the interviewees received an interview guide (Annex I), including 
background  information  about  the  study  and  a  topic  list.  The  topics  for  the  interviews 
included:  

  Updates  and  comments  to  the  general  conclusions  of  the  initial  study  on 

Corruption in the Healthcare Sector; 

  Developments in the relevant thematic areas since 2013; 
  Current  challenges  with  regard  to  the  thematic  areas  relevant  for  the 

stakeholder group;  

  Examples of good practices since 2013; 
  Cases since 2013.  

2.3.  Fact finding missions 
The aim of the fact-finding missions in each selected country was to deepen the knowledge 
on the specific themes highlighted in the EU Anti-Corruption Report.  

Before  each  fact-finding  mission,  relevant  interviewees  were  identified  (representing 
different stakeholder groups) through desk research/our initial contacts, and approached 
for an interview in the country. Prior to the missions, we sent them the interview guide. 
The topics for the interviews included:  

  Updates  to  and  comments  on  the  general  conclusions  of  the  initial  study  on 

Corruption in the Healthcare Sector; 

  Developments in the relevant thematic areas since 2013; 
  Current  challenges  with  regard  to  the  thematic  areas  relevant  for  that 

stakeholder group;  

  Examples of good practices since 2013; 
  Cases since 2013; 
  Country  and/or  stakeholder  specific  questions  based  on  the  results  of  desk 

research.  

Based  on  each  country  visit,  we  delivered  a  brief  mission  report.  These  are  detailed  in 
Chapter 3. In order to compare the results of the different missions, we used a common 
template in order to analyse the collected data in a standardised way.  

Per mission, about five interviews were conducted face-to-face, with follow-up by Skype 
or phone interviews where necessary. The interviewees included representatives of: 

  Transparency International national chapter or local partner; 
  National anti-corruption bureau or agency;  
  Ministry of Health; 
  National EHFCN contact point (if available); 
  Contacts interviewed for the initial study (SCH1); 
  EU medical devices contact points, vigilance contact points, clinical Investigation 

contact points, and other contact points; 

  Experts  from  academia,  the  media,  NGOs,  or  for  example,  the  EU  Group  of 

experts on corruption;  

  Other  stakeholders  (Government  regulator,  Healthcare  provider,  Medical 

devices supplier, Pharmaceutical supplier, Payers of healthcare). 

28 

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

2.4.  Desk research 
We carried out desk research throughout the study: in the early stages to review European 
developments in order to prepare the EU-level interviews and fact finding missions, and 
later  to  follow-up  on  specific  issues  mentioned  during  the  (thematic  and  fact-finding) 
interviews. 

The  desk  research  involved,  amongst  others,  the  following  key  publications:  the  special 
Eurobarometer  on  Corruption  (Eurobarometer  2014/397),  reports  on  Corruption  in 
Healthcare from Transparency International (e.g. on lobbying), EC report on Health Care 
and  Long-term  Care  Systems  &  Fiscal  Sustainability  (2016)5,  as  well  as  Healthcare  in 
Transition reports and OECD publications (e.g. ‘Health at a Glance Europe 2016’). In each 
of the country studies (Chapter 3) we refer to the Euro Health Consumer Index, as it ranks 
health  systems  according  to  their  performance  on  several  relevant  indicators,  including 
patient  rights  and  information,  accessibility,  outcomes,  range  and  reach  of  services. 
However, please be aware that some scholars have recently cautioned against this kind of 
ranking  of  health  systems6,  and  that  the  information  provided  is  thus  for  illustrative 
purposes only. 

We also reviewed websites, news items, and broader developments related to the six areas 
for thematic deepening, at the European level and also specifically for the countries of the 
fact-finding missions:  
1.  Informal payments in medical service delivery; 
2.  Certification and procurement of medical devices; 
3.  Authorisation and procurement of pharmaceuticals; 
4.  Privileged access to medical services (including not only informal payments but also the 

use of privileged information and information peddling);  

5.  Improper  marketing  by  pharmaceutical  companies  and  medical  device  producers  (at 
national  and/or  EU  level,  including  for  market  authorisation  and  reimbursement 
approval); 

6.  Potential risks involving double practice in public and private clinics. 

5 Commission services (Directorate-General for Economic and Financial Affairs), Economic Policy Committee 
(Ageing Working Group). Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. 
Brussels: 7 October 2016. Available at: https://ec.europa.eu/info/publications/economy-finance/joint-report-
health-care-and-long-term-care-systems-fiscal-sustainability-0_en.  
6 What, if anything, does the EuroHealth Consumer Index actually tell us? Blog by Cylus, Nolte, Figueras and 
McKee, BMJ, February 9, 2016. Available at: http://blogs.bmj.com/bmj/2016/02/09/what-if-anything-does-the-
eurohealth-consumer-index-actually-tell-us/.  

29 

 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

3.  COUNTRY STUDIES 

Introduction 

We  conducted  fact-finding  missions  in  Croatia,  Lithuania and  Romania  during December 
2016  and  in  Hungary,  Poland  and  Greece  during  January-February  2017.  Fact-finding 
missions were organised for three days on average, and combined whenever feasible.  

The country reports are all structured in the same way and cover the following topics: 

  Overview of the organisations interviewed; 
  General description of the healthcare system; 
  Risks and obstacles; 
  Types of healthcare corruption; 
  Recent cases; 
  Challenges and conclusions. 

31 

 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

3.1.  Greece 

Overview/summary 

The  fact-finding  mission  to  Athens,  Greece  took  place  between  6  and  9  February  2017. 
During this mission, six interviews were held. An overview of the interviews conducted is 
presented below. 

Table 3.1 Overview of Interviews conducted 

Date 
7-2-1017 
7-2-2017- 
7-2-2017 
8-2-2017 
8-2-2017 
9-2017 

Organisation  
EKPIZO 
- 
SEIV 
Panteion University 
- 
YPEDYFKA 

Stakeholder category 
Patients (Consumer organisation) 
Academic 
Providers 
Academic 
Civil society 
Payer / Regulator 

Note: please mark in red the information for which the interviewee has not given explicit consent for publication.  

3.1.1.  General description of the healthcare system 
In Greece, there is a mixed healthcare system: an NHS type system (which is called ESY 
in Greece) coexists with a social health insurance system.  

Statutory financing is based on taxes and social insurance contributions (which may differ 
across insurance companies) by employees and employers. These two financing methods 
are  approximately  equal  in  size.  The  third  source  of  financing  of  the  Greek  healthcare 
system  is  private  expenditure,  mainly  in  the  form  of  out-of-pocket  payments  on,  for 
example, pharmaceuticals.  

After  the  economic  downturn  in  Greece  in  2010,  many  reforms  were  adopted  in  the 
healthcare sector as well as in other sectors. Probably the most significant reform was Law 
3918/2011, which introduced a major restructuring of the system. One of the main changes 
was the clustering of all major social insurance funds into one fund, i.e. EOPYY, which acts 
as  the  sole  buyer  of  healthcare  services,  medical  devices,  and  pharmaceuticals.  This 
increase  in  bargaining  power  is  accompanied  by  the  introduction  of  regional  planning  of 
procurement of health supplies through the development of Regional Programs for Goods 
and Services. Another value added by the establishment of EOPYY is that there is now only 
one regulation governing contracts, with the result that the same rules apply to all patients. 

The regulation of healthcare services is quite centralised in Greece. The Ministry of Health 
is responsible for national healthcare policy (including priority setting for both health policy 
and  public  health),  the  regulation  and  management  of  EOPYY  (the  sole  payer),  the 
regulation of the private sector, and overall management of the healthcare system.  

With the establishment of EOPYY, there was the shift from multiple control bodies to one 
control  body  for  social  insurance.  YPEDYFKA  (which  was  already  established  in  2003)  is 
responsible for the control, auditing and monitoring of claims filed with EOPYY. Although it 
is part of the social health insurance fund, YPEDYFKA is highly independent and authorised 
to  independently  conduct  investigations.  As  all  claims  and  complaints  are  now  received 
centrally, there is a better overview of what is happening.  

YPEDYFKA in 2016 
In 2016, YPEDYFKA conducted 298 inspections and 250 evaluations that resulted in a penalty, which can be 
either a fine or a temporary suspension of a healthcare professional. Of all the cases investigated in 2016, 
27  involved  pharmaceutical  companies,  and  181  physicians  were  investigated.  The  offences  that  were 
detected cover a wide range of fraudulent or corrupt activities such as incorrect/undue charges, collaboration 
between physicians and pharmaceutical companies, and prolongation of hospitalisation. The vast majority of 
cases (94% in 2016) were detected on the basis of complaints made by patients. YPEDYKA has to investigate 
all the complaints they receive, but are faced with serious resource constraints; they only have 30 people 
available to look into complaints, conduct controls and impose penalties. As a result, YPEDYFKA hardly has 
any time for preventive proactive inspections – all available time is dedicated to following up on complaints.  

32 

 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Healthcare delivery 

In Greece, primary healthcare is provided by both public (ESY) and private providers. For 
primary  healthcare  provided  through  social  insurance  funds,  patients  can  only  choose 
between  the  contracted  providers.  Primary  care  physicians  currently  do  not  have  a 
gatekeeping function, but reforms have recently been announced that will change this. 

Secondary  and  tertiary  care  is  provided  in  two  different  settings:  public  hospitals  and 
private clinics (which play an important role in the provision). People can choose any public 
hospital for receiving treatment – there are no restrictions in terms of choice.  

EU average 

2015 (or 
nearest year) 
8.2% 
60.6% 
3% (2013) 
30.7% (2013)  13.9% 

10% 
77.8% 
2.2% 

8.9% 
66.7% 
3% 
28.8% 

Table 3.2 Indicators of the healthcare system in Greece 

Indicators of the healthcare system 
Financing of the healthcare system (1) 

2012 

Total health expenditure as % of GDP 
Public expenditure as % of total health spending 
Private insurance as % of total health spending 
Private-out-of-pocket as % of total health spending  
Organisation of the healthcare system (2) 
Social insurance or tax-based system? 
Gatekeeping by a general practitioner (GP)? 
How are physicians paid? (e.g. salary, fee-for-service, 
capitation) 
Patient organisation involvement (3=good, 
2=intermediary, 1=not-so-good) 
Accessibility (3=good, 2=intermediary, 1=not-so-good) (3) 
Family doctor same day access 
2 
Major surgery < 90 days 
Cancer therapy < 21 days 
CT scan < 7 days 

1 

2 
2 
3 

Mixed system 
Not necessary 
Salary 

(1) 

OECD 

Sources: 
OECD: 
DOI:10.1787/health_glance-2015-graph156-en,  Eurostat  healthcare  expenditure  by  financing  agent  (2)  Joint 
Report on Health systems (2010), HEIDI WIKI and EuroHealth Consumer Index 2012; (3) EuroHealth Consumer 
Index 2012. 

DOI: 10.1787/data-00349-en, 

expenditure 

indicators’ 

‘Health 

Table 3.3 Corruption in healthcare perception in Greece 

Corruption in healthcare perceptions  
Do you think that the giving and taking of bribes, and the abuse of positions of power 
for personal gain, are widespread among people working in the public health sector?  

(% of respondents agree - Eurobarometer) 

2011* 

75% 

2014** 

81% 

EU 
average** 
33% 

Sources: * Special Eurobarometer 374, table QC4 (fieldwork September 2011); ** Special Eurobarometer 397, 
2014 (fieldwork February - March 2013), Annex IV. 

33 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Table 3.4 Corruption Perception Index (CPI), Greece 

Corruption Perception Index 

Score 

Rank 

2016 

44* 

69*** 

Source: www.transparency.org; * CPI score is based on a scale ranging from 0 to 100, a score of 0 indicates a 
country is perceived as very corrupt and a score of 100 indicates a country is perceived as very clean; ** the 
2012 CPI ranked 174 countries, where a lower rank indicates a cleaner country; *** the 2016 CPI ranked 176 
country.  
countries, 

indicates 

cleaner 

where 

lower 

rank 

a 

a 

3.1.2.  Risks and obstacles 
Within the Greek healthcare system many risks and obstacles exist, which all increase the 
opportunities for corrupt and/or fraudulent behaviour.  

Underfunding and no clear and predictable budget allocation between hospitals 

Underfunding of the Greek healthcare sector is a large problem, which is also considered 
one  of  the  main  causes  of  corruption.  Between  2010  and  2014,  the  public  funding  on 
healthcare decreased from 70% to 60%. In contrast, the private funding increased from 
30% to 40% and private payments increased from 27% to 35%.[5] The share of healthcare 
expenditure in household consumption rose from 5.3% in 2010 to 5.9% in 2014, while in 
the  same  period  total  household  consumption  fell  by  24%  as  a  result  of  the  crisis.  The 
increase in private expenditure was mainly the results of changes in the reimbursement 
rule for pharmaceuticals; the OOP7 contribution has increased, and at the same time, the 
number of medicines on the reimbursement list has declined. It is estimated that patients’ 
part in pharmaceutical expenditure increased from approximately 12% to 31% between 
2010 and 2014. This is particularly problematic for the chronically ill and pensioners.  

In addition to underfunding, the resources available are not allocated efficiently. There is 
one  general  budget  for  the  healthcare  sector,  but  this  budget  is  not  divided  between 
hospitals or between specific departments within a hospital, e.g. cardiology. According to 
multiple interviewees, it is not transparent how the money is spent and the system does 
not provide any incentives to spend the money efficiently. For example, a physician does 
not  have  a  budget  available  to  cover  for  equipment  or  devices  required  –  he  is  free  to 
choose how much he spends on these items and the costs will be covered by the hospital. 
As  a  result,  efficient  spending  does  not  have  priority  for  the  physician;  he  /  she  will  be 
refunded anyway. 

Closely  linked  to  the  underfunded  system,  are  the  low  salaries  of  physicians.  Although 
salaries  have  always  been  low,  they  have  decreased  further  during  the  crisis.  Since  the 
crisis, salaries have been cut by 30%. On average, a physician earns 1,200 – 1,500 Euros 
per  month.  The  salaries  do  not  depend  on  the  medical  discipline  or  the  physician’s 
productivity. As a result of the low salaries, physicians seek different ways to increase their 
income. Examples mentioned by the interviewees include: 

  Asking patients for additional payments (under the table payments); 
  Declaring more hours than that they have actually worked; 
  Asking for money / gifts / sponsorships from providers. 

Overcapacity of physicians 

Another big problem in Greece is the large number of physicians. This is also highlighted 
in  the  recent  publication  on  Health  Care  and  Long-term  Care  Systems  &  Fiscal 
Sustainability  (2016)8:  in  2013,  there  were  629  physicians  per  100,000  inhabitants  in 

[5] See press release Hellenic Statistical Authority (31 March 2016).  
7 OPP = out of pocket. 
8 Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability Volume 2 Country 
Documents, Institutional paper 037, October 2016.  

34 

 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

Greece, while the EU average was 344 per 100,000 inhabitants in that same year. There 
are more physicians – particularly medical specialists - than the system needs and, as a 
result, the competition among physicians is high. Although some physicians have moved 
abroad,  the  number  of  available  physicians  is  still  high,  especially  compared  to  other 
countries. As a result of the overcapacity, salaries (public physicians) and earnings (private 
physicians)  are  under  pressure  and  decreasing.  In  order  to  increase  their  income, 
physicians are more willing to accept informal payments, declare more hours than actually 
worked, or ask providers for money, gifts or sponsorships. In addition, specifically within 
the  private  sector,  there  are  also  cases  of  avoiding  tax  payments  in  order  to  increase 
earnings. 

Lack of a functioning primary care system 

A major problem in the Greek healthcare system is the lack of a well-functioning primary 
healthcare system. Currently this is almost non-existent, especially in the larger cities. In 
rural areas there is a form of primary care. In the larger cities, patients go straight to a 
hospital  outpatient  or  emergency  department  to  receive  care.  For  example,  emergency 
care is used to obtain access to a hospital bed, even when the patient is not in acute need 
of medical assistance. One interviewee noted that effectively the bed goes to the highest 
bidder, or to the patient with the best hospital connections, not the patient in most acute 
need of care. 

In the past, several attempts have been made by the Greek government to re-introduce 
the  primary  healthcare  system.  However,  so  far  these  attempts  have  failed.  In  the 
attempts, no links were created between primary care and hospitals, and primary care is 
therefore  a  standalone  system.  In  April  2017,  the  Ministry  of  Health  announced  new 
reforms  for  the  primary  healthcare  system,  which  will  introduce  primary  healthcare 
services at both the first and second level, as well as a gatekeeping system. At the first 
level, services will be provided by Local Health Units (ToMY) and private practices that are 
contracted by EOPYY. At the second level, health centres will provide services9.  

Unqualified hospital managers 

The interviewees indicated that they have a strong impression that hospital managers are 
often not the most capable or suitable persons for running a hospital. The political affiliation 
of the hospital manager appears to be more important than his / her managerial skills or 
knowledge about the healthcare system. This leads to inefficient hospital management, a 
lack of budgetary control and wrong decision-making. The joint report on Health Care and 
Long-term  Care  Systems  &  Fiscal  Sustainability  (2016)10  notes  that  progress  has  been 
made  in  this  area,  however  “the  system  has  not  fully  succeeded  in  isolating  political 
interventions from decision making”. 

Unstable political climate 

It is important to keep in mind that political cycles are very important in shaping (long-
term)  policies  to  fight  corruption.  As  several  of  the  main  risk  factors  for  corruption  in 
healthcare in Greece are fundamental issues in the healthcare system (as described in this 
Chapter), long terms plans and structural reforms to the system are essential in the fight 
against this problem. This has, for the last few years however, been complicated by political 
instability and frequent shifts in power. When the political climate is stable, changes to the 
system can made. However, when the political climate is unstable, as it has been in Greece 

9 Online Health Systems in Transition (HiT) profile of Greece – updated on 01/06/2017. 
http://www.hspm.org/countries/greece09062014/livinghit.aspx?Section=5.1%20Physical%20resources&Type=
Section. 
10 Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability Volume 2 Country 
Documents, Institutional paper 037, October 2016.  

35 

 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

in recent years, it is likely that not much structural reform will or can happen. In addition, 
the fact that the Minister of Health in Greece has changed quite frequently has also led to 
political instability; during the last 7 years, 6 different people have been Minister of Health. 
The frequent changes of power imply that policies are mainly focused on the short term; 
not many long-term plans are developed, as they are politically not feasible.  

The disciplinary board 

When  physicians  are  caught  asking  for  bribes  they  face  a  hearing  with  the  disciplinary 
board. This board predominantly consists of other physicians. Interviewees estimated that, 
in  approximately  90%  of  cases,  this  disciplinary  board  drops  the  charges  against  the 
physicians and lets them go without punishment. There are, however, no official numbers 
available to support this claim. Physicians are also allowed to return to the same position 
they were working in before being caught. Some stakeholders pointed out that the signals 
given by the board are counterproductive as they indicate that a physician can get away 
with requesting a bribe. In addition, it discourages patients from reporting such incidents, 
and sometimes even makes them fear for their own or someone else’s health.  

Lack of reporting and control  

It is difficult to detect corruption in the Greek healthcare system, as patients are naturally 
unwilling to report bribes or other forms of corruption. People tend to not talk about this 
problem as they are usually in a state of dependency. If people are willing to talk, they can 
file a complaint/report (either in person or anonymously) via several phones numbers that 
have been established for the purpose. There are some whistleblowing systems in place in 
Greece, but the available systems are rather vague and complicated. Since 2013, no new 
whistleblowing  systems  have  been  developed.  This  is  partly  because  Greece  has 
‘complicated’  whistleblowing  laws.  For  example,  the  ‘double-edged-sword’  laws  (saying 
that the corruptor and corrupted are both criminally liable) discourages people to report. 
In addition, it appears that the institutions behind these phone numbers generally fail to 
take adequate action.  

Officially, an anti-corruption bureau has been established which is also tasked with fighting 
corruption  in  the  healthcare  system.  One  stakeholder  however  mentioned  that, to  date, 
not much progress has been made. 

In addition, the Greek legal system is very complicated, especially in terms of the Penal 
Code. Based on the Penal Code, physicians could be prosecuted for taking bribes, however 
this is rarely done. It should also be noted that it takes a considerable time before a final 
verdict  in  a  criminal  case  is  obtained.  It  can  easily  take  10  –  15  years  before  the  case 
comes  to  a  final  conclusion.  This  lack  of  capacity  within  the  judicial  system  creates  big 
risks; it sends out a signal that there is a very real chance that corrupt behaviour will go 
unpunished.  It  is  important  to  note  that  this  is  not  a  problem  of  capability;  the  judicial 
system is considered one of the least corrupted powers in Greece as it manages to maintain 
a certain degree of independence. 

Finally, there is no political willingness to actively prosecute corruption. In a recent case, 
evidence  was  collected  showing  that  225  Greek  physicians  were  involved.  All  these 
physicians appeared on the pay-roll of the company; however, prosecution of the case has 
progressed  very  slowly.  Early  in  2016,  it  was  announced  that  a  court  case  was  being 
prepared, but to date (August 2017), only three doctors (all orthopaedic surgeons) have 
been  convicted  of  bribery  and  embezzlement  of  2  million  EUR.  Although  all  received  a 
prison  sentence,  none  of  them  went  to  prison  as  the  sentences  were  on  probation.  The 
three doctors maintain they are innocent.11 

11 https://www.vice.com/gr/article/wn9b8m/giatroi-apo-thn-8essalonikh-katadikasthkan-gia-to-skandalo-
depuy.  

36 

 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

Cultural aspect 

A  final,  but  not  to  be  overlooked,  risk  for  (petty)  corruption  is  the  cultural  aspect. 
Physicians, and other public officials, requesting a bribe for (privileged) access or better 
quality  treatment  is  considered  accepted  practice.  This  can  create  insecurities  among 
patients about what will happen if they refuse to pay. Moreover, people sometimes also 
consider it normal to make informal payments as a way of thanking the physician.  

Informal payments; 

3.1.3.  Types of healthcare corruption 
In Greece, many forms of corruption exist. The main forms reported during the fact-finding 
mission were: 
 
  Double practice; 
 
  Corruption in procurement; 
  Clientelism; 
  Overcharging by technical services; 
 

Improper marketing; 

Induced demand.  

It should be noted that the latter three types of corruption / fraud are not the focus of this 
study; however, these types were mentioned multiple times during the interviews.  

Informal payments 

Informal  payment  is  still  seen  as  the  most  prevailing  type  of  corruption  in  Greece.  The 
perception is that the problem of under-the-table payments has increased over the years. 
This  is  partly  due  to  the  declining  salaries  of  physicians.  In  addition,  the  use  of  public 
hospitals has increased, as people no longer have the money to pay for private hospitals. 
It is this combination of increased demand and decreased salaries that has resulted in an 
increase in physicians asking for informal payments for better quality and/or quicker access 
to  healthcare  services. This  is  aggravated  by the  fact that  there  are still  no  transparent 
waiting lists in Greece. One speciality where typically a lot of money is paid under the table 
is surgery. The exact amount of the payment depends on the level of complexity of the 
surgery as well as the organ/part of the body that is operated on (the highest payments 
are made for heart or brain surgery). 

Although informal payments have increased, they also have become less visible. Often the 
physician will not ask explicitly for a payment, but will use other means of making clear 
that a payment is required. Some of the interviewees mentioned that that the physicians 
will create insecurity for the patient in order to force him / her to pay. 

Insecurity on who is going to perform surgery 
When someone needs surgery, a physician might tell the patient that not he but his assistant will perform 
the surgery as his own schedule is fully booked. The patient will become insecure because he/she wants the 
surgeon himself to operate. The patient will start offering bribes to get access to this higher quality of care. 
Creating such insecurity is an important cultural aspect. 

Informal  payments  are  not  only  made  to  physicians;  they  can  also  be  made  to  other 
personnel,  e.g.  nurses  often  receive  a  gratuity  for  small  favours  offered.  Nurses  also 
receive payment for securing hospital beds. 

Bribery for hospital beds 
Stakeholders mentioned that heads of departments typically have the ‘right’ to reserve approximately 3-4 
beds for themselves, to allocate to patients as they wish. Other physicians typically have 1 or 2 beds. This is 
an ‘unwritten law’ in hospitals and facilitates the preferential treatment of patients based on informal relations 
or payments. In addition, there is an interconnection between staff, such as nurses and physicians, which 

37 

 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

makes the problem even worse. For example, people may pay a nurse or have a nurse in their family, who 
can then ask the physician to reserve a bed for them/provide more immediate treatment. 

It is also important to note that bribery, or corruption in general, is not only a problem in 
the public sector. There is also a black economy within the private sector. In the private 
sector, a patient is often offered a discount when he/she agrees not to receive a receipt 
for payment of the treatment. In such cases, the physician is able to generate non-taxable 
income.  

Double practice 

The problem of double practice is a relatively new problem in Greece. Until some years ago 
physicians in hospitals used to be employed fully as civil servants. As a consequence, they 
were not allowed to work in the private sector as well. Currently, some physicians have 
other types of contracts, which allow them to work, under conditions, in both the public 
and  private  sector.  Moreover,  some  public  physicians  (still  being  civil  servants)  are  also 
illegally active in the private sector.  

Corruption  in  the  context  of  double  practice  works  as  follows:  the  patient  will  visit  the 
private clinic, where he/she will pay the physician under-the-table in order to get to the 
top  of  the  waiting  list  when  applying  in  the  public  hospital.  Once  on  top  of  the  list,  the 
patient  will  be  treated  in  the  public  facility.  Hence,  informal  payments  are  made  for 
preferential access through another route. 

Improper marketing 

Despite  the  fact  that  direct  sponsorship  is  allowed  under  Greek  law,  the  larger  medical 
device manufacturers and distributors aim to prohibit direct sponsorship. However, as was 
pointed out by the medical technology association in Greece (SEIV), only the members of 
the association, who will adopt the new MedTech Code (expected in second half 2017), will 
be  bound  by  the  prohibition.  Many  smaller  companies  are  still  allowed  to  offer  direct 
sponsorship, something that is willingly accepted by physicians, for whom little educational 
budget  is  available.  Although  direct  sponsorship  is  legally  allowed,  several  larger 
companies do perceive it as unethical behaviour, which should be stopped.  

Corruption in procurement of medical devices 

In Greece, multiple cases of corruption within public procurement processes for medical 
devices and pharmaceuticals have occurred. In order to combat this problem, the Greek 
government  established  a  central  procurement  body  that  is  solely  responsible  for 
procurement. However, this body is not functioning well, with the result that hardly any 
big tenders are procured. As hospitals still need their supplies, they tend to buy devices 
and products themselves, tendering them in smaller quantities, so that the procurement 
rules do not apply. This, in turn, provides risks and opportunities for corruption.  

Clientelism 

Hospital managers are often not the most capable manager or physician, but are political 
appointees. The political affiliation of the hospital manager is more important than work 
experience  and  knowledge  of  the  sector.  As  a  result,  hospital  management  becomes 
ineffective, budget control is lacking and wrong decisions are taken.  

Overcharging by technical services 

Although  not  directly  linked  to  the  types  of  corruption  elaborated  on  in  this  study,  the 
problem  of  overcharging  of  certain  hospital  related  services  was  mentioned  during  the 
interviews. All hospitals have internal technical services and these technical services are 
typically overcharging hospitals for the work/repairs they are doing.  

38 

 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Overpricing of technical services during the crisis (2012) 
An  anecdote  shared  related  to  a  hospital  where  the  technical  service  division  charged  15,000  Euros  for  a 
simple maintenance job, while a quotation from an outside company (requested on an own initiative by a 
cardiologist  in  the  hospital)  was  only  1,500  Euros.  This  means  the  technical  services  were  overpricing  by 
factor 10.  

Induced demand 

Another form of corruption mentioned that does not fall under the scope of this study, but 
was mentioned during the field mission, was the case of induced demand. Often physicians 
seem to prescribe fake prescriptions. Such prescription can take different forms: 
1.  Overcharging of medicine prices; 
2.  Prescribing medicines that are not actually needed; 
3.  Prescribing medicines that are not delivered to the patients. 

This latter category can also be an indication for parallel export.  

Another type of induced demand relates to the hospitalisation of patients. In some cases, 
the patient did not have an overnight stay in the hospital and consequently, the costs of 
hospital admittance are falsely claimed. In other cases, the patient was admitted to the 
hospital,  however  more  nights  are  claimed  than  that  the  patient  actually  stayed.  While 
undue charges and prescriptions are thus a big problem in Greece, none of the interviewees 
mentioned the use of fake patients, i.e. all undue charges were made for patients actually 
treated. 

An  important  cause  of  induced  demand  is  the  information  asymmetry  between  patients 
and healthcare providers. Induced demand is also caused by broadly defined contracts that 
leave room for interpretation. At the time of the fact-finding mission, new contracts are 
under negotiation and were expected to be in force as of Q2 2017. 

3.1.4.  Recent cases 
During  the  fact-finding  mission  several  cases  where  mentioned.  These  cases  received 
media  attention  and  were  debated  in  Greek  society.  It  should  be  noted  that  little  to  no 
investigation and/or prosecution in those cases was undertaken.  

Pharmaceutical company: suspicion of bribery of physicians and public officials12 
In January 2017, it was reported that the Greek Authorities had raided the office of a pharmaceutical company 
in Athens, Greece. The company stands accused of bribing physicians and public officials in order to increase 
their market share on the Greek pharmaceutical market.  

The investigation is based on reports received through hotlines. Media reports indicate that at least 4,000 
public and private physicians are involved in the scandal. The company exerted pressure on the physicians 
to buy innovative and expensive anti-cancer drugs. The company’s executive in Greece attempted suicide on 
New Year’s night, which fuelled further suspicions.  

Officials indicate that the scandal is not only related to Greece, but that physicians in other countries are also 
involved.  

Medical service provider: suspicion of bribery of hospital staff 
In  this  case  hospital  employees,  who  were  part  of  the  procurement  decision  process,  were  bribed  by  a 
company  specialising  in  medical  equipment  to  favour  tender  processes  and  the  purchase  of  medical 
equipment to the benefit of the accused. The investigation revealed that the company paid a wide array of 
medical  staff,  from  nurses  and  midwives,  operating  theatre  chiefs,  through  to  physicians,  professors,  and 
hospital directors.  

The  proceedings  included  cases  that  took  place  between  2001  -  2006  and  were  conducted  in  multiple 
countries. The bribes were disguised as fictitious services provided by the physicians for employees of the 
company  (for  example,  training,  symposiums,  and  overpaid  consultations)  in  exchange  for  money.  In 

12 http://mobile.reuters.com/article/idUSKBN14O156. 

39 

 
 
 
 
 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

exchange  for  the  bribes,  the  physicians  were  encouraging  other  physicians  to  become  interested  in 
purchasing the company’s equipment and they tried to qualify the highest number of patients for procedures, 
which  influenced  the  sale  of  the  specific  medical  equipment.  Apart  from  these  activities,  the  company 
sponsored physicians’ trips to symposiums and training events.  

In several countries, e.g. Poland and the US, the involved people have already been brought before court. In 
Greece, the investigation is still pending, although investigative authorities found evidence that shows that 
225 Greek physicians were involved. All these physicians appeared on the pay-roll of the company; however, 
none of the physicians has been punished to date. Early in 2016, it was announced that a court case was 
under  preparation,  but  only  eight  physicians  seem  to  have  been  brought  to  court.  Shortly  after  this 
announcement, it was communicated that the court case was postponed indefinitely. Proceedings resumed 
on  May  8th  2016,  however,  only  three  doctors  (all  orthopaedic  surgeons)  were  convicted  of  bribery  and 
embezzlement of 2 million EUR. Of the three, two received sentences of 11 years each and the third doctor 
received a sentence of 14 years. However, they are all free as the sentences were on probation, with the first 
two doctors free on a bail of 10 000 EUR each and the third with 15 000 EUR bail. They maintain they are 
innocent.13 

Corruption with reimbursement of healing dressing (2016) 
A  big  scandal  recently  uncovered  by  YPEDYFKA  (investigative  unit  of  EOPYY  –  the  sole  payer  in  Greece) 
related to the reimbursement of healing dressings used for ulcers. The e-prescription system (introduced to 
control medical expenditure on medicines) helped YPEDYFKA to uncover this type of corruption. Based on the 
data included in the system, it became clear that many more healing dressings were prescribed and against 
higher prices than were included in the price list (which sets the maximum price for different medicines).  

In order to receive reimbursement from EOPYY, it was required to upload a photo of the specific ulcer into 
the e-prescription system. Based on a photo comparison, YPEDYFKA established that some photos were used 
multiple times, even by different physicians. Hence, the claims for reimbursement were based on fake medical 
services.  After  thorough  investigation,  it  turned  out  that  around  1,000  physicians  were  involved  in  the 
scheme.  

This case received much media coverage. The physicians involved received a fine, which most of them have 
already paid. It was easy for YPEDYFKA to collect the fines, as EOPYY owned the physicians money (i.e. the 
reimbursements).  The  fines  were  subtracted  from  that  amount.  EOPYY  has  also  decided  to  decrease  the 
reimbursement for the healing dressings as a result of this scandal. 

3.1.5.  Recent policy developments14 
Recently, different policies have been adopted. Some of the policies have been adopted by 
the central government, other by individual bodies (e.g. EOPYY) and some by the industry. 
The level of success differ widely. 

Policies by public authorities 

The anti-corruption strategy 

In 2013, the Ministry of Health published its anti-corruption plan, which specifically focuses 
on  the  healthcare  sector.  This  plan  had  to  be  written  as  part  of  the  structural  reforms 
needed to help Greece out of its economic depression. All measures included in the plan 
aim to fight corruption in the Greek healthcare system. However, it is unclear if the plan 
was actually implemented. Many of the stakeholders doubt the effectiveness of the plan 
and indicate that it is just another document that seems to have ended up in the drawer.  

Prescription of active substances / generics 

The Greek government adopted an initiative in which physicians are no longer allowed to 
prescribe a specific brand of medication. The attempts to increase generics have not been 
very  successful;  penetration  of  generics  is  still  relatively  low  in  Greece  (approximately 
20%).  The  policy  that  physicians  can  only  prescribe  the  active  substance  rather  than  a 
branded pharmaceutical shows some promise in promoting generics. However, to date, no 

13 https://www.vice.com/gr/article/wn9b8m/giatroi-apo-thn-8essalonikh-katadikasthkan-gia-to-skandalo-
depuy.  
14 At the time of the fact-finding mission, i.e. early February 2017.  

40 

 
 
 
 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

results have been obtained, and it is therefore difficult to indicate whether or not this new 
policy is successful.  

Price observatory for medical devices 

The  government  introduced  a  price  list  –  the  Price  Observatory  –  which  presents  the 
maximum  prices  for  different  types  of  equipment/devices.  These  maximum  prices  are 
based on the lowest price that was paid for such a device/piece of equipment in Greece in 
previous years. This observatory also records the prices from other EU Member States, and 
devices cannot be sold in Greece for prices higher than paid for the same devices in other 
EU  countries.  Whether  or  not  this  observatory  list  is  successful  is  debated  among  the 
stakeholders interviewed. Some see a clear value added by the list as it helps to combat 
corruption, while others think the list, in its current form, takes away all possibilities for 
competition and forces companies into a deadlock situation. Also, the list does not allow 
for price differences based on geographical differences. For example, delivering equipment 
in  Athens  is  cheaper  than  on  one  of  the  smaller  islands  (as  a  result  of  higher  transport 
cost). 

E-prescription system 

The e-prescription system is seen as a good practice by many stakeholders. A first attempt 
to introduce such a system was launched in 2003. At that time, the system was filled with 
scanned  prescriptions,  which  were  included  in  one  overall  database.  Between  2003  and 
2010, not much happened and the system was not very active. In 2010, a new format for 
e-prescriptions was launched and this system has been actively rolled out since 2012. The 
introduction has been gradual, starting with medicines (which now have 100% coverage), 
and  followed  by  other  healthcare  services.  These  days  it  covers  all  kinds  of  healthcare 
services  (e.g.  hearing  aids,  glasses,  lab  tests  and  hospitalisation).  Currently  more  than 
26,000 medical service providers are included. 

Online patient health records 

A few years ago, EOPYY introduced the so-called patient health records, which are available 
online. For each patient, a record is made which provides insights into the care received, 
in terms of both services and medicines. The patient can check the status of this record 
and when the patient detects an irregularity, he/she can report this to YPEDYFKA, who can 
then  can  begin  an  investigation.  In  this  way,  the  patient  records  help  to  reduce  fake 
prescriptions as the patient can check whether or not the records are actually true. It is 
unclear at the moment to what extent the system is used by patients. There is, however, 
the expectation that patients have the incentive to use the system as they are becoming 
increasingly suspicious, mainly as a result of the crisis.  

Price list for medicines and hospital supplies 

The price list for medication is quite new and easy accessible. However, it is not known 
whether elderly patients are able to check this list, as it is only published online. It is also 
not known whether patients check this list before going to the physician. Nevertheless, it 
is noted that patient awareness of costs and prices has increased during the last couple of 
years. In addition, patients are becoming more critical and suspicious towards physicians, 
especially  regarding  what  they  prescribe.  This  has  also  led  to  an  increase  in  complaints 
from patients. 

EOPYY  has  also  introduced  its  own  price  list.  This  price  list  is  meant  for  hospitals  and 
indicates to them what the regular prices are, for certain supplies. The enforcement of this 
list will be done by SEYP, who are responsible for the control and monitoring of hospital 
expenditures.  

41 

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Disease register 

EOPYY recently introduced registries for certain diseases. In each registry, it is laid down 
who  is  suffering  from  a  particular  disease,  what  medication  is  prescribed  and  how  far 
advanced the disease is. An example of such a registry is the registry for hepatitis. The 
registry can help to check how money is spent also how much money is spent. It will enable 
authorities to assess whether the money is being correctly spent and make prognoses for 
future costs, which is very useful for negotiations. It is the intention of EOPYY to expand 
this system and include more diseases into it. 

Change in reimbursement rules 

Another new policy introduced by EOPYY relates to the new rules on reimbursement. EOPYY 
will reimburse the physician directly instead of reimbursing the patient (which is the current 
practice). The patient no longer has to pay in advance for the part that is reimbursed by 
EOPYY.  

Industry related initiatives 

Adoption of the MedTech Code of Ethical Business Practice 

The  Medical  technology  association  has  already  translated  the  newly  adopted  MedTech 
Code of Ethical Business Practice. In June, a General Assembly will be held in which the 
association’s  members  will  be  asked  to  adopt  the  Greek  translation.  It  seems  that  the 
companies  are  willing  to  do  so  and  it  is  likely  that  from  June  onwards  the  Code  can  be 
implemented  among  the  members.  The  Code  needs  to  be  implemented  by  2020  at  the 
latest.  It  is  likely  that  larger  companies  will  also  apply  the  Code  to  their  distributors, 
irrespective  of  whether  they  are  members  of  SEIV.  As  a  result,  the  impact  of  the  Code 
could reach further than members only. 

A  new  aspect  in  the  MedTech  code  is  the  phasing  out  of  direct  sponsorship.  This  is  an 
aspect  that  is  difficult  to  regulate,  and  currently  there  is  much  debate  among  members 
and  other  equipment  producers  /  distributors  on  this  topic.  Physicians  are  keen  on 
accepting direct sponsorships, especially as educational funds in Greece are very limited. 

3.1.6.  Challenges and conclusions 
In  Greece, petty  corruption  remains  a big  challenge.  The  problem  has  only  increased  in 
recent years as a result of the combination of higher demand for public healthcare and the 
decline in wages for physicians. Although it is a major challenge for the Greek healthcare 
system and society in general, it does not appear to be a priority in anti-corruption plans 
for the healthcare sector as there have not been many policies or initiatives to tackle (the 
root causes of) this problem; the problem does not seem to get the attention it needs and 
deserves.  

One of the main problems in the Greek healthcare system is that is underfunded. Given 
the  current  economic  climate  and  the  required  budget  cuts,  it  is  also  one  of  the  most 
difficult problems to solve. However, efficient allocation of the resources that are available 
would already be an important step in the right direction. The challenge for Greece is thus 
to strive for efficiency in allocation of the scarce resources available. The joint report on 
Health  Care  and  Long-term  Care  Systems  &  Fiscal  Sustainability  (2016)15  also 
acknowledges  this  as  an  important  challenge  for  Greece.  Stakeholders  agree  that  the 
implementation of a functioning primary healthcare system can have an important role in 
this  respect.  By  establishing  such  a  system  and  giving  it  a  gatekeeping  function,  self-
referrals to the hospitals and admission via emergency rooms can be reduced. The recently 

15 Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability Volume 2 Country 
Documents, Institutional paper 037, October 2016.  

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announced reform of the primary healthcare system in Greece, including the introduction 
of a gatekeeping system, is a promising development. 

Only  after  establishing  the  proper  infrastructure,  with  qualified  people  in  managing 
positions,  can  the  focus  shift  to  changing  mentality  and  behaviour.  As  long  as  the 
healthcare  system  is not  functioning  properly  and  people  have no trust  in  the  system  – 
which  is  currently  the  case  -  policies  aimed  at  changing  mentality  will  not  reach  their 
potential.  For  such  policies,  it  will  also  be  important  that  people  are  educated  on,  for 
example, how to deal with information asymmetries. This would require action from civil 
society organisations, which are currently not active in Greece in the field of anti-corruption 
in healthcare.  

Another major challenge for Greece is the functioning of the judicial system. The system 
is currently facing major capacity constraints. As a result, cases are only prosecuted after 
10  to  15  years  (if  at  all),  which  sends  the message  that people  and  companies  can  get 
away with corrupt practices.  

Some  stakeholders  believe  that  decent  plans  are  sometimes  developed,  and  relevant 
studies  are  conducted,  but  that  there  is  subsequent  lack  of  implementation.  The  main 
reasons for this are the lack of resources and, maybe even more importantly, the lack of 
political will to fight corruption and the unstable political climate. Because of this unstable 
climate,  all  actors  in  the  healthcare  sector  are  operating  in  a  risky  environment  and 
frequent changes within the Ministry, policies and legislations make it difficult to keep up 
and plan ahead.  

Hence,  preconditions  for  the  implementation  of  successful  policies  to  fight  corruption  in 
healthcare  in  Greece  include:  implement  and  support  recent  (announced)  changes  to 
fundamental  elements  of  the  healthcare  system  (including  the  set-up  of  a  primary 
healthcare  system,  which  is  currently  ongoing),  reforms  in  the  judicial  system,  active 
involvement of civil society, and – very important – political stability.  

Looking from a broader perspective, there have been some promising developments. For 
example, the anti-corruption Secretariat General at the Ministry of Justice. Although it does 
not deal with petty corruption – only high-level corruption – it is a good practice in itself. 
Moreover,  the  SEYYP,  the  Inspectorate  of  Health  and  Welfare  in  Greece,  has  been 
investigating  cases  of  corruption  and  produces  reports  with  their  findings  and 
recommendations. Another example of a promising development is the translation of the 
MedTech Europe code into Greek and the aim to implement it by mid-2017. Though there 
are some concerns with regard to the implementation, the fact that efforts are made to 
ban direct sponsorship, thereby reducing the risks for improper marketing, is an important 
step. Another example concerns the role and functioning of YPEDFYFKA. They have been 
successful  in  investigating  a  large  number  of  cases  and  punishing  physicians  and 
companies  for  fraudulent  behaviour  and  misconduct.  A  final  example  concerns  a 
development, which took place after the fact-finding mission in February 2017, namely the 
development of an electronic anti-corruption platform to monitor informal payments. The 
platform is being developed by the Ministry of Health, and aims to facilitate reporting and 
subsequent investigation of the reports by the authorities16.  

16 http://greece.greekreporter.com/2017/04/14/greek-health-ministry-announces-e-platform-to-address-
countrys-health-care-corruption/.  

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3.2.  Croatia 

3.2.1.  Overview/summary 
The fact-finding missions to Zagreb, Croatia, took place from 12 – 14 December 2016. Five 
interviews  with  stakeholders  from  different  categories  were  undertaken  in  person.  An 
overview can be found below. 

Table 3.5 Overview of Interviews conducted in Croatia 

Date 
12/12/2016 
12/12/2016 

13/12/2016 

13/12/2016 
14/12/2016 
12/01/2017 

Organisation  
Croatian Medical Chamber 
Coalition of Associations in 
Healthcare 
Ministry of Justice, Anti-Corruption 
Sector 
Innovative Pharmaceutical Initiative 
Croatian Ombudsman 
Ministry of Health 

Stakeholder category 
Providers 
Patients 

Regulator 

Industry 
NGO 
Regulator 

Furthermore, we have received answers in writing from USKOK (national anti-corruption 
agency) and from HALMED (regulatory agency for medicines). 

3.2.2.  General description of the healthcare system17 
In  2015,  Croatia  ranked  16th  out  of  35  European  countries  in  terms  of  healthcare 
performance in the Euro Health Consumer Index.18  

At the central level, the Ministry of Health is responsible for policy-making, planning and 
evaluation, and public health programmes. The responsibility for the management of health 
services  at  the  local  level  has  been  delegated  to  municipalities  and  local  authorities. 
Ownership  of  the  hospitals  is  shared  between  the  central  government  and  local 
authorities.19 

There is a mandatory health insurance system, and the sole insurer is the Croatian Health 
Insurance Fund (CHIF or HZZO in Croatian). It is a quasi-public body and is overseen by a 
director and board of directors who are appointed by the Croatian government, following 
the Minister of Health’s recommendation. It is the main purchaser of health services, sets 
performance  standards,  sets  prices  for covered  services,  and  handles  payments  for  sick 
leave compensation, maternity benefits, and other allowances. Complementary voluntary 
health insurance (which involves user charges) is also provided mainly through the CHIF. 

In  2013,  the  CHIF  was  funded  by  a  combination  of  health  insurance  contributions  of 
employers  and  employees  (76%)  and  financing  from  the  State  budget  (15%). 
Complementary  financial  resources  are  out-of-pocket  payments  and  private  health 
insurance.  In  line  with  the  decentralisation  of  healthcare  services,  local  governments 
increasingly contribute to the public expenditures in healthcare.  

The provision of public health services is done through a network of one national institute 
and  21  county  institutes.  Although  citizens  are  required  to  register  with  a  general 
practitioner  (GP)  or  paediatrician,  patients  often  seek  healthcare  services  directly  at 
hospitals. At the same time, GPs do function as gatekeepers, as prescriptions can only be 
acquired via GPs, and payments for hospital services from the health fund are only made 
after feedback on treatment has been sent to the GP. There have been no attempts so far 
to establish integrated care pathways. Since 2013, GPs have been given financial incentives 
by CHIF to create group practices. 

17 Main source for this section is the WHO/European Observatory ‘Health Systems in Transition’ report on 
Croatia (2014).  
18 See http://www.healthpowerhouse.com/en/news/euro-health-consumer-index-2015/.  
19 See http://www.hspm.org/countries/croatia30062014/countrypage.aspx.  

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Pharmaceuticals are procured by the CHIF for all of Croatia. They calculate prices on the 
basis of three reference countries, lowered by 5%. There is reference pricing: a product 
below the baseline falls under category A, and above the baseline into category B. Category 
B involves co-payment by patients. In addition, there is a list of expensive drugs. In 2013, 
the essential medicines list had 3455 drugs that are fully paid for by CHIF. The additional 
list has 760 drugs, for which an additional payment is required. High cost medicines and 
orphan drugs are available through hospitals.20 

There is a risk sharing mechanism in place with the pharmaceutical industry for expensive 
drugs. Costs of consumption of drugs in total health costs are high (20%). The main payer 
is  the  CHIF,  while  private  insurance  companies  offer  some  additional  services,  such  as 
partial reimbursement of hospital costs.21 

Regulatory oversight 

The  Agency  for  Medicinal  Products  and  Medical  Devices  (HALMED)  provides  services 
pertaining to medicinal products, medical devices and homeopathic medicinal products, in 
accordance with the primary and secondary legislation of the Republic of Croatia. Its tasks 
include market authorisation and quality control of medicinal products, the regulation of 
medical  devices,  and  monitoring  of  adverse  reactions.  It  determines  which  drugs  are 
reimbursed,22  and  has  various  committees  whose  memberships  can  be  seen  on  the 
website.23 Information about procedures and lists of approved drugs can also be viewed 
here, increasing transparency of the organisation’s operations.  

The  key  players  in  public  procurement  generally  are  the  Directorate  of  the  Public 
Procurement  in  the  Ministry  of  Economy,  Entrepreneurship  and  Crafts,  the  Ministry  of 
Finance for concessions, the Agency for Investments and Competitiveness for PPPs, and 
the State Commission for the Supervision of Public Procurement Procedures. Information 
related  to  public  procurement  in  the  healthcare  sector  is  made  publicly  available  on 
HALMED’s  website,  including  the  procurement  plan,  ongoing  public  procurement 
procedures, the registry of public procurement contracts and framework agreements. 

Table 3.6 Indicators of the healthcare system in Croatia 

Indicators of the healthcare system  
Financing of the healthcare system (1) 

Total health expenditure as % of GDP 
Public expenditure as % of total health spending  

2012 

7.8% 
81.61% 

Private insurance as % of total health spending  
Private-out-of-pocket as % of total health spending  

- 
- 

Organisation of the healthcare system (2) 
Social insurance or tax-based system? 

Gatekeeping by a general practitioner (GP)? 

How are physicians paid? (e.g. salary, fee-for-service, 
capitation) 
Patient organisation involvement (3=good, 
2=intermediary, 1=not-so-good) 
Accessibility (3=good, 2=intermediary, 1=not-so-good) 

Social 
insurance 
Public: 
compulsory 
Capitation 

3 

2015 (or 
nearest year) 
7.8% (2014) 
81.87% 
(2014) 
1.4% (2014) 
11.21% 
(2014) 

EU 
average 
10% 
77.8% 

2.2% 
13.9% 

20 See http://www.ispor.org/CeeNetwork/documents/Health_care_system_reimbursement_policy_croatia.pdf. 
21 Ibid. 
22 See 
http://www.hspm.org/countries/croatia30062014/livinghit.aspx?Section=2.8%20Regulation&Type=Section.  
23 See http://www.halmed.hr/en/O-HALMED-u/. 

46 

 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

Indicators of the healthcare system  
Family doctor same day access 
Major surgery < 90 days 
Cancer therapy < 21 days 
CT scan < 7 days 

3 
1 
3 
1 

Sources: (1) WHO/European Observatory ‘Health Systems in Transition’ report on Croatia (2014), OECD Health 
at  a  Glance  Europe  (2016),  (2)  World  Bank  healthcare  statistics,  Eurostat  healthcare  statistics,  European 
Commission (2016), Joint Report on Healthcare and Long-Term Care Systems and Fiscal Sustainability.  

3.2.3.  Risks and obstacles 
A  broader  issue  with  regard  to  corruption  in  healthcare  relates  to  the  politicisation  of 
Croatian public institutions – not only in healthcare, but also in the media. An artefact of 
the old communist era is that when the political colour of the government changes, the 
leadership  in  the  healthcare  sector  (and  other  public  institutes)  also  changes.  The 
governing party replaces, for example, hospital directors and the director of the CHIF. This 
type of behaviour (political appointees) is regarded as ‘normal’ behaviour by society.  

In addition, the system is such that personal interests can play a big role. For example, an 
association  can  be  founded  with  just  three  citizens,  so  if  there  are  conflicts  within  an 
organisation, this is sometimes solved by establishing another organisation. This leads to 
inefficiency  and  ultimately  runs  the  risk  of  having  personal  interests  prevail  over  public 
interests. Furthermore, as Croatia is a small country, there are only about 10-15 people 
that  are  key  experts  in  their  field  and  these  are,  because  of  their  expertise  and  status, 
subject to less strict scrutiny by the general public.  

On  the  healthcare  system  in  general,  there  are  concerns  that  the  quality  of  healthcare 
provided is not equal among all healthcare providers, and that there is too much focus on 
healthcare in the capital Zagreb (and urban areas) to the detriment of healthcare in other 
regions of the country, especially the Croatian islands. There is no national accreditation 
programme of hospitals, there is no systematic data available on the quality of healthcare 
services, and there is no clear performance indicator system in place.  

Structural challenges for Croatian healthcare are further related in the National Health Care 
Strategy 2012-202024 and concern:  

 

the strengthening of the connections and continuity throughout the healthcare 
system (organisation of care); 
standardising and improving the quality of healthcare; 
 
increasing efficiency and effectiveness of the healthcare system; 
 
  making health care more available and improving health indicators.  

The  risks  of  corruption  are  –  to  some  extent  –  inversely  related  to  the  performance  on 
meeting these challenges. 

Table 3.7 Corruption in healthcare perception in Croatia 

Corruption in healthcare perceptions  
Do you think that the giving and taking of bribes, and the abuse of positions of power for 
personal gain, are widespread among people working in the public health sector?  

(% of respondents agree - Eurobarometer) 

- 

56% 

2011* 

2014** 

EU 
average** 
33% 

Sources: * in 2011 Croatia was not part of EU(27); ** Special Eurobarometer 397, 2014 (fieldwork February - 
March 2013), Annex IV. 

24 See 
https://zdravlje.gov.hr/UserDocsImages/dokumenti/Programi,%20projekti%20i%20strategije/National%20Heal
th%20Care%20Strategy%202012-2020.pdf.  

47 

 
 
 
 
 
 
 
 
                                                 
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Table 3.8 Corruption Perception Index (CPI), Croatia 

Corruption Perception Index 

Score 

Rank 

2016 

49* 

55*** 

Source: www.transparency.org; * CPI score is based on a scale ranging from 0 to 100, a score of 0 indicates the 
country is perceived as very corrupt and a score of 100 indicates a country is perceived as very clean; ** the 
2012 CPI ranked 174 countries, where a lower rank indicates a cleaner country; *** the 2016 CPI ranked 176 
countries, where a lower rank indicates a cleaner country.  

3.2.4.  Types of healthcare corruption 
In  2013,  94%  of  Croatians  indicated  that  corruption  is  widespread  in  their  country.25 
Paradoxically, this may be because of the success of Croatia’s Bureau of Suppression of 
Corruption  and  Organised  Crime  (USKOK)  in  prosecuting  high-level  officials,  cases  that 
feature prominently in the media. In addition to complementing USKOK’s achievements, 
Croatia was complimented by the European Commission for its creation of an electronic 
database for public procurement, increasing transparency. In 2015, Croatia ranked 50th 
on the TI Corruption Perceptions Index rank listing of 168 countries.26 

There is a difference between the perception of corruption and corruption in practice. The 
media play an important part in increasing the perception of corruption – i.e., some cases 
are given lots of emphasis in the media, even if it is an old case. This is not to say that 
there  is  no  corruption,  however  due  to  underreporting  of  corruption  and  the  focus  of 
attention on certain cases in the media, public views on corruption in healthcare are not 
necessarily aligned with the scope and affected areas. 

Double practice 

In Croatia, it is not possible for physicians to hold a private practice in public hospitals, but 
physicians  can  work  in  both  public  and  private  hospitals  (double  practice).  In  the  old 
system, the Minister of Health needed to approve a licence for a physician willing to work 
in private practice. A new rulebook with regard to double practice was adopted last year. 
In the new (current) system, a physician needs approval from the hospital director where 
he/she works in order to work in a private practice as well. In addition, the physician must 
prove that the work at the public hospital is at least at the level of the national average, 
or  else  a  physician  cannot  even  apply  for  a  private  practice  license.  Finally,  the  private 
practice needs to sign a contract with the public hospital, specifying the exact number of 
hours and services to be performed by the physician. A private practice that employs public 
sector physicians cannot have a contract with the CHIF; these costs can only be paid out 
of pocket by a patient. 

Double practice is considered a problem, because the physicians working in private clinics 
do not have enough energy to perform their work properly at the public hospitals. People 
prefer  private  hospitals  because  they  are  quicker  and  more  efficient.  This  may  be 
problematic with regard to equal access. Stakeholders, however, support the combination 
of public and private healthcare, and some even argued that having private practice could 
lower waiting lists in public hospitals. 

From 2002-2004 there was a strong media campaign against double practice. At that time, 
the accusations may have had some merit: two physicians that tried to avoid working in 
the  public  hospital  were  caught  in  2002.  Today,  changes  have  been  made,  for  example 
through  the  implementation  of  the  DRG  (payment)  system,  and  the  CHIF  maintains  a 

25 See Special Eurobarometer 397, http://ec.europa.eu/public_opinion/archives/ebs/ebs_397_en.pdf.  
26 See Transparency International Report here http://www.transparency.hr/upload_data/site_files/corruption-
perceptions-index-2015-report.pdf.  

48 

 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

register  where  it  is  easy  to  check  whether  a  double  practice  physician  performed  the 
procedures to be reimbursed by the CHIF. 

Informal payments 

In Croatia, three factors play a role with regard to the issue of bribery for medical services. 
Firstly,  there  is  a  historical  heritage  of  communism,  where  it  was  common  to  express 
gratitude  to  physicians.  Secondly,  Croatia  was  always  a  part  of  a  bigger  country  unit 
(Austro-Hungary, Yugoslavia), so there was a general predisposition to avoid taxes (they 
are  now  working  to  change  this  attitude.)  Thirdly,  Croatia  is  part  of  the  Mediterranean 
cultural circle. If you go to a friend’s place, it is the norm that you bring a box of chocolates, 
or a bottle of wine.  

Interviewees stressed the fact that it is important to make a distinction between a gift and 
a  bribe.  For  a  long  time  it  has  been  common  to  bring  a  bottle  of  spirits  or  some  coffee 
when  visiting  a  physician,  which  is  perceived  as  a  small  gift  just  to  show  appreciation. 
Bribery takes place at the level of politicians, and involves much bigger gifts, according to 
several interviewees. However, this practice may lead to problems as it is blurring the lines 
between (more or less ‘acceptable’) gifts and straightforward bribes. The cultural habits 
are, however, different from country to country. 

Gifts  to  physicians  are  becoming  less  common.  The  culture  is  changing,  also  because 
attention is paid to the risk of corruption during medical education. In addition, it is now 
regulated  through  the  Conflict  of  Interest  Act.  This  cultural  change  has  taken  place  in 
society over the last 15 years.27 

3.2.5.  Recent cases 

Case ‘X affair’ – bribery between a pharmaceutical company and physicians 
USKOK provided the following facts and figures about the ‘X affair’ (2013). In the X affair, 364 physicians 
and a pharmaceutical company were indicted for having committed several criminal offences – associating 
to commit criminal offences, taking and giving bribe, abuse of power and authority, and instigating the abuse 
of power and authority. The 1st accused person was the Management Board president of a pharmaceutical 
company, the 2nd accused person was the executive director of corporate affairs and director of controlling 
of  the  company  sales,  whereas  the  3rd  accused,  4th  accused  and  5th  accused  were  regional  directors  of 
certain  sectors.  They  were  indicted  for  the  criminal  offence  of  bribing  a  large  number  of  physicians  and 
pharmacists between 2009 and October 2012 to achieve the highest possible sales rates for certain drugs. 
They established and managed a continuous connection of larger number of physicians and pharmacists in 
the Republic of Croatia who received bribe from the pharmaceutical company.  

Bribes  were  provided  in  the  form  of  value  tickets,  money,  paid  travel  arrangements  on  behalf  of  the 
pharmaceutical company, as well as other gifts in the value of five to ten per cent of the value of prescribed 
drugs. 

Final  convicting  judgments  have  been  rendered  for  313  persons  (of  which  297  are  physicians  and  16  are 
‘other’ persons - veterinarians, pharmacists etc.). Most persons pled guilty to avoid lengthy procedures. It 
concerned mostly low-level cases. 

These prosecuted persons have also been taken up by the independent disciplinary Court of Honour of the 
Medical Chamber. This Court can proclaim a physician to be unworthy to practise. Two penalties are possible: 
lose  your  license  with  probation,  or  lose  your  license  without  probation.  Some  277  trials  were  completed 
during the last six months. There were 267 penalties of physicians losing their license with probation. Only 
three physicians lost their license without probation, and 6 physicians have been cleared. 

Between  2014  and  2015  there  was  only  one  other  formal  case,  and  this  concerned  a 
disciplinary  affair.  In  the  Court  of  Honour  there  are  two  types  of  procedures:  one  to 
determine  whether  one  can  still  practise  medicine,  the  other  concerns  a  disciplinary 

27 The turning point was when, 15 years ago, some 10 doctors were discovered to provide false disability 
testimonials in return for money. 

49 

 
 
 
 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

procedure. The first is mandatory, the other is not. The one case referred to above was 
also  about  a  bribe,  and  was  reported  by  another  physician,  who  referred  him  to  the 
disciplinary procedure. 

Furthermore, from the interviews it became clear that there has also been a hospital which 
changed the medicines for a chronic patient group without a clear reason (such as quality 
or  cost).  This  was  done  because  the  hospital  director  had  made  an  agreement  with  a 
pharmaceutical company to prescribe a specific type of drug. However, this never became 
a big case in the media. 

3.2.6.  Recent policy developments 

Healthcare 

Whereas  reforms  between  2006  and  2013  focused  on  financial  stabilisation  of  the 
healthcare  system,  reforms  between  2014  and  2016  focused  on  preserving  financial 
stability and increasing efficiency in the sector.  

An important change is that Croatia has had a unified public procurement in place since 
2013. Before 2012, some hospitals paid up to four times as much for identical products. 
Access  to  the  same  level  of  service  and  quality  of  products  was  not  guaranteed,  even 
though there is one national health insurance scheme.28 Nowadays, one specific hospital 
acquires a certain product/service for all of Croatia. The government appointed 9 state-
owned  hospitals  and  the  Croatian  Health  Insurance  Fund  (CHIF  or  HZZO)  as  central 
authorities,  responsible  for  the  procurement  of  a  range  of  products.  Joint  procurements 
were widely challenged by manufacturers through legal means, but this has generally been 
unsuccessful. The estimated savings from the concluded joint tenders up to February 2014 
were EUR 59 million or about 27%, compared to prices paid before the introduction of joint 
procurement.29  

A more fundamental change occurred as of 1 January 2017, when the Parliament adopted 
a new procurement law, which replaces ‘lowest cost’ with ‘economic price’, which also takes 
into account actual quality as the main evaluation criterion. As part of the "economic price" 
criterion,  the  relative  consideration  of  price  or  cost  cannot  be  higher  than  90%.  In  the 
negotiated  procedure  without  prior  publication,  framework  agreements,  the  awarding  of 
Social  and  other  specific  services,  and  procurement  for  defence  and  security,  that 
percentage  can  be  higher  than  90%.  The  recommendations  from  health  technology 
assessments are included in the procurement. 

In  2014,  Croatia  applied  for  a  World  Bank  loan  to  introduce  a  number  of  reforms  to  its 
healthcare  sector.  Under  the  identified  priority  of  ‘preserving  financial  stability  of 
healthcare’,  it  lists  reducing  corruption  and  informal  payments.30  The  latest  World  Bank 
progress report states that Croatia’s reforms are beginning to yield results.31 At the same 
time,  the  overall  risk  rating  remains  ‘moderate’.  Better  measurement  of  progress  and 
communication  of  the  reforms  (to  key  stakeholders)  would  contribute  to  strengthening 
reform momentum. 

In 2015, the CHIF was separated from the State Treasury to improve health protection and 
reduce waiting lists.32 This boosted the public healthcare budget by 2.2bn Croatian kuna 

28 See http://www.lse.ac.uk/LSEHealthAndSocialCare/pdf/EuroHealthVol20No2.pdf, in particular Table 1 (on 
p.30). 
29 Ibid., p.32. 
30 See http://documents.worldbank.org/curated/en/2014/04/19416051/croatia-improving-quality-efficiency-
health-services-project and Article19(vii) in underlying document. 
31 See http://www-
wds.worldbank.org/external/default/WDSContentServer/WDSP/ECA/2015/10/24/090224b08316908b/1_0/Rend
ered/PDF/Croatia000Heal0Report000Sequence005.pdf.  
32 See https://about.hr/news/croatia/healthcare-system-gets-hrk-22-billion-more-2015-4259.  

50 

 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

(approximately  EUR  91  million).33  A  new  financing  scheme  for  hospitals  has  been 
introduced, aimed at achieving savings and to promote functional integration of hospitals 
that have unsustainable financial positions.34 However, implementation of the reforms has 
not proceeded apace.35  

A process to draft a new healthcare law was started about two years ago, and would have 
changed,  amongst  other  things,  the  position  of  hospitals.  However,  due  to  frequent 
changes in government over the past few years (and resulting changes in preferences for 
what the new healthcare law should address), the process has stalled, and no new law has 
been introduced (or even drafted) yet.  

Anti-corruption36 

Croatia has a dedicated anti-corruption unit involved in prosecuting cases, that is called 
USKOK,37  operates  under  the  State  Attorney’s  office,  and  a  dedicated  sector  under  the 
Ministry  of  Justice,38  which  is  responsible  for  developing  anti-corruption  policies  and 
coordinating  anti-corruption  initiatives  between  various  governmental  actors  and  other 
stakeholders. The Sector (Ministry of Justice) has about 3.5 FTE and has been operating 
for the last three years. 

In 2015, an anti-corruption strategy was adopted by the Croatian Parliament, and yearly 
action plans to implement it have been developed. The anti-corruption strategy includes a 
chapter  about  health,  which  proposes  transparency  improvements  in  terms  of  gifts  to 
physicians, enforcement of the legal framework, strict surveillance of public procurements, 
and waiting lists, and also includes measures to increase the trust between physicians and 
patients, shorten waiting lists, improve efficiency in the healthcare sector and improve the 
satisfaction of patients and employees.  

None of the health actions have been fully implemented, and only a few have been partially 
implemented.  The  action  plan  for  2017-2018  needs  to  be  adopted,  and  consultations 
between the Ministry of Health and the anti-corruption sector of the Ministry of Justice have 
already taken place. Although the proposed measures in the area of health are quite good, 
the proposed actions to implement these measures are not very satisfactory to the sector. 

As the responsible policy-unit, the anti-corruption sector of the Ministry of Justice asks the 
relevant  (government)  stakeholders  (e.g.  Ministry  of  Health) to  carry  out  an  analysis  of 
risks and problems regarding their own sector; and these serve as inputs for the action 
plans.39 The different corruption themes from the 2013 Study on Corruption in Healthcare 
overlap to a large extent with the ones in the Croatian anti-corruption strategy. 

The Ministry of Justice collects quarterly monitoring reports from the various stakeholders, 
who  need  to  report  progress  with  regard  to  the  measures  in  their  action  plans.  These 
monitoring reports go to the Council for Anti-Corruption, a monitoring body that includes 
USKOK,  NGOs,  and  representatives  from  the  Agency  for  Access  to  Information  and  the 
Agency  for  Conflicts  of  Interest.  Afterwards,  there  reports  are  then  presented  to  the 

33 Exchange rate on 1 July 2015. 
34 See 
http://ec.europa.eu/economy_finance/economic_governance/documents/201503_hr_imbalances_epc_report_e
n.pdf.  
35 See 
http://ec.europa.eu/economy_finance/economic_governance/documents/20160118_hr_imbalances_epc_report
_en.pdf.  
36 An overview of Croatia’s anti-corruption regulatory framework can be found here: http://rai-see.org/croatia-
anti-corruption-institutional-framework/.  
37 See section above and http://www.dorh.hr/Default.aspx?sec=19.  
38 As part of the Directorate European Affairs, International and Judicial Cooperation. 
39 The Croatian Medical Chamber was involved as a sub-stakeholder from the Ministry of Health. 

51 

 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

government.  There  is  also  a  Parliamentary  monitoring  body,  which  receives  the  reports 
from the government. 

implemented,  due 

The action plan for 2015-2016 was adopted in June/July 2015. In the healthcare sector, 
in 
not  many  actions  were 
leadership/government over the past two years. Political stability should partially address 
this issue, as will ongoing consultations with the Ministry of Justice. At the same time, it 
seems a strengthening of the Ministry of Health through hiring a policy officer to function 
as  an  anti-corruption  expert  in  healthcare  would  seem  desirable,  since,  at  present, 
evaluating healthcare from an anti-corruption perspective is not yet ingrained within the 
Ministry. 

frequent 

changes 

the 

to 

The government has also recently codified the distinction between a gift and a bribe in the 
Conflict of Interest Act, which specifies that all gifts worth more than 500 Croatian kuna 
count as bribery.  

Furthermore, the CHIF has a register of which companies pay for example for the education 
of which physicians. Sponsoring by industry is still allowed, but it is regulated. The personal 
information in these registries  is not by default open to the public, only if the physician 
consents to it. General information on how many physicians are sponsored and the total 
amount paid is, however, public.  

3.2.7.  Challenges and conclusions 
There  have  been  no  indications  of  systemic  corruption  since  the  2013  case.  Combating 
corruption is taken seriously by the government, which has adopted regulations to lower 
the  risks  for  corruption  and  an  anti-corruption  strategy;  as  well  as  by  the  providers  of 
healthcare  and  by  the  industry  itself,  which  both  pay  attention  to  the  issue,  attempt  to 
increase transparency, and have ethical agreements amongst themselves (self-regulation) 
and with the CHIF to combat corruption. 

At the same time, it is notable that there have not been any complaints to the Ombudsman 
regarding corruption in healthcare even though the perception of corruption among citizens 
is  relatively  high  in  Croatia.  It  seems  that  there  is  underreporting  of  corruption  cases, 
and/or  a  mismatch  between  which  kind  of  corruption  reaches  the  public  sphere  (a  few 
high-profile cases) and what is going on in terms of actual corruption (more lower level 
‘petty’ corruption). 

An  important  issue  regarding  the  regulatory  framework  for  tackling  corruption  is  that 
Croatia currently does not have whistle blower protection.  

A  challenge  is  that  the  Ministries  with  whom  the  dedicated  anti-corruption  sector  of  the 
Ministry  of  Justice  collaborates  to  develop  the  anti-corruption  strategy  and  action  plans 
often have no dedicated anti-corruption policy officers. Anti-corruption is not necessarily 
the first priority for the Ministries, as there are other, more pressing issues to deal with (in 
light also of the changes in the government over the last two years). 

Remuneration in hospitals remains a concern, also, in light of discrepancies between urban 
and rural hospitals, and staff wages, the framework for incentivising should be looked into. 
This  is  important  for  fiscal  sustainability,  but can  have  a  knock-on effect  on  combatting 
corruption.  

Corruption is highlighted as a point of attention in the Croatian Health Care Strategy, and 
it is important that ownership of this strategy – and the relevance of combatting corruption 
- is increased among all stakeholders. The two latter challenges were also reported in the 
recent  publication  on  Health  Care  and  Long-term  Care  Systems  &  Fiscal  Sustainability 
(2016).  

52 

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

3.3.  Lithuania 

3.3.1.  Overview/summary 
The  fact-finding  mission  field  mission  to  Vilnius,  Lithuania  took  place  from  12  –  14 
December  2016.  Five  face-to-face  interviews  with  members  from  different  stakeholder 
categories were undertaken. An overview can be found in Table 3.9.  

Table 3.9 Overview of Interviewees in Lithuania 

Date 

Organisation  

Stakeholder category 

12/12/2016 

IFPA – Innovative Pharmaceutical Industry 

Industry  

Association 

13/12/2016 

National Health Insurance Fund (VLK) 

13/12/2016 

Transparency international  

14/12/2016 

-  

14/12/2016 

Ministry of Health  

Payer 

Other  

Research  

Regulator  

Note: please mark in red the information for which the interviewee has not given explicit consent for 
publication.  

3.3.2.  General description of the healthcare system 
Lithuania  has  a  mixed  system  of  compulsory  statutory  health  insurance,  providing 
universal coverage. The National Health Insurance Fund (VLK), a semi-autonomous state 
monopoly under the Ministry of Health, is the third-party payer in this system. All basic 
services  are  covered  and  provided  free  of  charge.  The  benefit  package,  as  well  as  the 
contributions and prices paid to providers, are established by law.  

The VLK is funded through a combination of social insurance contributions and allocations 
from the state budget. The funds are managed by the State Patient Fund. Another source 
of funding is out-of-pocket payments, mainly for pharmaceuticals and excluded services. 
Although  private  health  insurance  is  available  in  Lithuania,  it  is  not  purchased  by  many 
people. One of the main reasons for this is the high insurance premiums.  

The healthcare system in Lithuania is organised at two levels: national and municipal. The 
Ministry of Health plays an important role in the system and is responsible for the regulation 
and general supervision of the healthcare system. The municipalities are responsible for 
providing primary and social care, public health activities, and running polyclinics and small 
to medium sized hospitals within their jurisdiction.  

Healthcare delivery 

In  Lithuania  healthcare  is  provided  by  public  providers  (either  state-managed  or  under 
municipal governments) and private providers. Primary care is provided by GPs or primary 
care  teams  and  is  mainly  financed  through  capitation.  The  majority  of  the  healthcare 
institutions are not-for-profit. The public providers are financed by the VLK. In 2012 a new 
hospital financing system using DRGs was introduced.  

Private healthcare institutions provide mostly outpatient services. They can be contracted 
by the VLK or are paid by patients out-of-pocket. In general, these private providers have 
the potential to offer higher quality treatments and/or treatments that are not available in 
public healthcare institutions.  

53 

 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Table 3.10 Indicators of the healthcare system in Lithuania 

Indicators of the healthcare system 
Financing of the healthcare system (1) 

2012 

2015 (or 
nearest year)  

6.7% 
65.2% 
0.8% 
31.8% 

6.6% (2014) 
67.9% (2014) 
2.1% (2014) 
31.3% (2014) 

EU 
averag
e 
10% 
77.8% 
2.2% 
13.9% 

Mixed system  
Financially 
encouraged 
Capitation/FFS/Bon
us 
3 

Total health expenditure as % of GDP  
Public expenditure as % of total health spending  
Private insurance as % of total health spending 
Private-out-of-pocket as % of total health spending 
Organisation of the healthcare system (2) 
Social insurance or tax-based system? 
Gatekeeping by a general practitioner (GP)? 

involvement 

organisation 

How are physicians paid? (e.g. salary, fee-for-service, 
capitation) 
Patient 
2=intermediary, 1=not-so-good)  
Accessibility (3=good, 2=intermediary, 1=not-so-good) 
Family doctor same day access 
Major surgery < 90 days 
Cancer therapy < 21 days 
CT scan < 7 days 

(3=good, 

2 
2 
3 
2 

Sources:  (1)  The  World  Bank  ‘health  expenditure’,  WHO/European  Observatory  ‘Health  Systems  in  Transition’ 
report on Lithuania (2016), OECD Health at a Glance Europe (2016), Eurostat healthcare expenditure by financing 
agent,  (2)  World  Bank  healthcare  statistics,  Eurostat  healthcare  statistics  and  underlying  data  for  indicators, 
European Commission (2016), Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability. 

Table 3.11 Corruption in healthcare perceptions in Lithuania 

Corruption in healthcare perceptions  
Do you think that the giving and taking of bribes, and the abuse of positions of power 
for personal gain, are widespread among people working in the public health sector?  

(% of respondents agree - Eurobarometer) 

64% 

74% 

2011* 

2014** 

EU 
average** 
33% 

Sources: * Special Eurobarometer 374, table QC4 (fieldwork September 2011); ** Special Eurobarometer 397, 
2014 (fieldwork February  -  March 2013);  own research  (fieldwork  February/March 2013). No new  information 
was found in the Eurobarometer of 2013. 

Table 3.12 Consumer Perception Index (CPI), Lithuania 

Corruption Perception Index 

Score 

Rank 

2016 

59* 

38*** 

Source: www.transparency.org; * CPI score is based on a scale ranging from 0 to 100, a score of 0 indicates the 
country is perceived as very corrupt and a score of 100 indicates a country is perceived as very clean; ** the 
2012 CPI ranked 174 countries, where a lower rank indicates a cleaner country; *** the 2016 CPI ranked 176 
countries, where a lower rank indicates a cleaner country.  

3.3.3.  Perception of corruption 
In 2016, the Lithuania Corruption Map was published. This Corruption Map is the result of 
a  survey  amongst  three  target  groups:  residents  (n=1,002),  business  leaders  (n=503), 
and civil servants (n=502)40, which was initiated by the Special Investigation Service and 

40 There is no overlap between the target groups, i.e. each individual can only belong to one of the three target 
groups for this survey.  

54 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

conducted  by  an  independent  research  centre41.  The  survey  revealed  that  56%  of 
Lithuanian residents consider corruption in general to be a serious problem, and that 42% 
think the problems have grown in the last 5 years. Important to note here is that while 
people  perceived  an  increase,  the  percentage  of  people  reporting  has  decreased 
substantially over the years: where it was 77% in 2011, it was 53% in 2014, and reduced 
to 42% in 2016. Hence, it seems that overall progress has been made, but that there is 
still room for improvement. 

Looking specifically at the healthcare sector, the Lithuania Corruption Map 2016 indicates 
that  51%  of  the  residents  consider  healthcare  institutions  to  be  the  most  corrupt 
institutions in the country. In addition, hospitals and clinics appear to be the institutions 
with  the  highest  bribes  extortion  and  giving  indices.  Nevertheless,  these  indices  have 
improved since 2014: for town/district hospitals from 0.53 to 0.36, for republican hospitals 
from 0.43 to 0.40, and for clinics from 0.32 to 0.16.  

3.3.4.  Risks and obstacles 
The  healthcare  sector  in  Lithuania  is  very  informal.  Many  people  consider  it  common 
practice  to  pay  small  bribes  to  physicians  in  the  form  of  either  gifts  or  money.  These 
informal payments (‘petty corruption’) are considered both a necessity for gaining access 
to  the  best  treatment,  as  well  as  a  way  of  showing  gratitude  towards  a  healthcare 
professional.  Petty  corruption  is  generally  accepted  by  society,  but,  as  pointed  out  by 
multiple stakeholders, this mentality is slowly changing. The new generation of patients is 
publicly stating that they are not willing to pay bribes, and young physicians are very active 
in the field of anti-corruption. 

Not  only  informal  payments,  but  also  informal  relations  can  play  an  important  role  in 
gaining access to treatment or finding a physician. This holds for all types of healthcare; 
from  family  doctor  to  tertiary  hospital  services.  The  importance  of  informal  relations 
creates risks for unequal, and privileged, access to healthcare.  

Informal relations also play an important role in the appointment of managers of healthcare 
institutions.  Over  the  last  years,  ownership  of  an  increasing  numbers  of  hospitals  has 
moved to the Ministry of Health and the municipalities. The managers, who are appointed 
by the owner, typically have political affiliations and are appointed based on their informal 
relations  (political  appointees)  rather  than  their  managerial  skills.  As  a  result,  many  of 
these managers have a perpetual conflict of interest and the managerial structure of many 
institutions is not effective (enough). 

Another  risk  in  the  healthcare  system  is  the  information  and  knowledge  asymmetry 
between different actors, such as between different parties within procurement, but also 
between  patients  and  providers  (e.g.  with  regard  to  medical  treatments,  but  also  with 
regard  to  reimbursement  for  specific  services).  When  one  actor  takes  advantage  of  the 
information/knowledge mismatch with another actor, this can lead to corrupt practices.  

Finally,  inefficient  resource  allocation  is  also  a  risk  in  the  Lithuanian  healthcare  sector. 
Stakeholders  differ  in  their  opinion  as  to  whether  or  not  the  total  healthcare  budget  is 
sufficient, but all agree that it is allocated in an inefficient manner. This can lead to waste 
or create incentives for corrupt practices. For example, it is common knowledge that the 
wages for physicians in Lithuania are low, which creates the risk of physicians asking for 
bribes, having multiple practices (sometimes up to 7 or 8), or leaving the country. Several 
stakeholders  mentioned  that  another  illustration  of  inefficient  allocation  of  funds  is  that 
there is hardly any money (made) available for evaluating anti-corruption initiatives, which 
is  key  in  identifying  effective  practices.  Two  stakeholders  also  mentioned  the  current 

41 Lithuanian Map of Corruption, 2016: http://www.stt.lt/lt/menu/tyrimai-ir-analizes/?print=1. 

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Updated Study on Corruption in the Healthcare Sector  

reimbursement system in this context, because this system is based on diseases and social 
groups, rather than on therapeutic value.  

3.3.5.  Types of healthcare corruption 
The main corruption problems in the Lithuanian healthcare sector concern: 

Informal payments (‘petty corruption’); and 

 
  Corruption in public procurement, both for medicines and for medical devices 

(‘big corruption’).  

Which of these two problems is the biggest depends on how you define big; most money 
is being lost to corrupt practices in public procurement, but informal payments are more 
widespread, and accepted as common practice by a large part of society.  

In addition to petty corruption and corruption in public procurement, improper marketing, 
privileged access (through informal relations), and double practice – which in itself is not 
illegal in Lithuania - are observed.  

Informal payments 

In Lithuania the problem of informal payments is widespread (not only in healthcare) and 
generally accepted by society. However, there has been a downward trend in the number 
of people that report having made informal payments: from 1 in 3 Lithuanians in 2010, to 
1 in 4 in 2013, to 1 in 6 at the end of 201542. This decreasing trend is confirmed by the 
results presented in the Lithuania Corruption Map 201643. People in Lithuania are generally 
aware  that  informal  payments  constitute  corruption  and  are  open  about  making  such 
payments. As a result of this, the size of the problem can be estimated rather accurate 
and a lot of information is publicly available.  

All interviewees mentioned that among young people, there seems to be a resistance to 
petty corruption – they openly question why they should pay for healthcare services that 
are reimbursed by the National Health Insurance Fund. Younger physicians also publicly 
state  that  they  do  not  take  bribes.  Hence,  the  change  in  generation  seems  to  create  a 
change in the thinking about informal payments.  

According to several stakeholders, the main causes for informal payments in the Lithuanian 
healthcare system are:  

 

Insufficient knowledge of patients with regard to healthcare services and their 
reimbursement; 

  Low wages for physicians; 
  The  mind-set  that  people  think  that  they  need  to  show  their  gratitude  to 

physicians through informal payments.  

The main impact of informal payments is that it creates a lack of trust in the public health 
insurance system; when people pay taxes for the health insurance and need to pay extra 
to ensure they receive proper healthcare, they lose trust in the system.  

Corruption in public procurement  

In  Lithuania,  there  is  a  central  procurement  system  in  place.  In  this  system,  the  Public 
Procurement Office (PPO) and the Central Procurement Organisation (CPO) are responsible 
for ensuring rational use of procurement using public funds and administrative resources. 
VLK uses CPO catalogues for the procurement of medicines that are either really expensive 

42 Numbers are based on results of surveys conducted by the Ministry of Health (for 2010 and 2013) and the 
Lithuanian Corruption Map that was developed by the Special Investigation Service (for 2015). (source: 
interviews during fact-finding missions).  
43 Lithuanian Map of Corruption, 2016: http://www.stt.lt/lt/menu/tyrimai-ir-analizes/?print=1. 

56 

 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

or only used by a small group of patients, or else are on the market with few competitors. 
Other medicines and medical equipment are typically bought by individual hospitals. 

The  Ministry  of  Health  tries  to  introduce  the  concept  of  ‘consolidated  purchases’  by 
encouraging big and small healthcare institutions to work together, and emphasising that 
this  consolidated  purchasing  will  enable  them  to  achieve  lower  prices.  Currently,  the 
number of purchases of medical devices through the central procurement system is lower 
than  for  pharmaceuticals.  Overall,  there  has  been  an  increase  in  the  use  of  the  central 
system.  

One stakeholder mentioned that for public procurement the main risk for corruption seems 
to be the mismatch between the levels of knowledge as well as the levels of influence of 
the different players.  

The latest research on public procurement in the healthcare sector in Lithuania stems from 
2008  –  no  systematic  research  on  this  topic  has  been  conducted  since,  which  makes  it 
difficult  to  estimate  the  current  extent  of  the  problem.  Based  on  a  2015  report  from 
Transparency International it is, however, possible to say something about perceptions, as 
this  study  reveals  that  41%  of  businesspeople  in  Lithuania  perceive  procurement  in  the 
healthcare sector not to be transparent44.  

Recently, public procurement data is open to the public, so everyone is now able to look 
up the cash flow. 

Double practice 

In  Lithuania  it  is  not  illegal,  and  actually  very  common  for  physicians  to  have  multiple 
positions in the public and private sector.  

In  2015  the  Ministry  of  Health  sough  to  estimate  the  size  of  the  problem  with  double 
practices. This was done based on the 2014 Law on Private Interest, according to which all 
physicians  had  to  declare  their  interests  in  2015  to  the  supreme  commission  on  ethics. 
When  looking  at  the  data  and  comparing  it  with  data  from  the  tax  authority  it  became 
apparent that a large number of physicians had not declared all their interests45. This made 
it impossible to make an accurate estimation of the size of the problem, but confirmed that 
double or multiple practices should be further investigated. In addition to the size of the 
problem, it is also very difficult to estimate the influence that these double/multiple practice 
activities have on the healthcare system.  

One  stakeholder  mentioned  that  there  were  the  suggestions  for  addressing  the  issue  of 
double  practice  by  not  allowing  physicians  in  the  private  sector  to  also  work  for  public 
institutions.  However,  analysis  showed  that  this  would  lead  to  a  significant  decrease  of 
physicians in the public sector, which is undesirable. The Ministry is now in the process of 
working  out  other  measures,  in  terms  of  reform  of  the  healthcare  system  that  could 
address the problem of double/multiple practices. The basis of the solution seems to be to 
offer good wages, so that physicians no longer have to think about other practices.  

Improper marketing 

On 9 December 2016, the new Minister of Health talked in his speech about the issue of 
illegal lobbying practices (referred to in the study as ‘improper marketing’). This is an area 
which, up to now, has not been properly managed in Lithuania – there is no legislation in 

44 Lithuanian business survey on lobbying - Attitudes towards Lobbying Activities, 2015. 
http://www.transparency.lt/wp-content/uploads/2015/10/verslininku_poziuris_i_lobistine_veikla1.pdf. 
45 At the time of fact finding mission no action was taken against the physicians that had not declared all there 
interest, no information was available on compliance in 2016. 

57 

 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

place with regard to lobbying. Lobbying is not necessarily a bad thing, but as there is a 
lack of relevant legislation in this area, there are risks for corrupt behaviour. The Ministry 
of Health is aware that there is still a lot of work to be done in this area.  

3.3.6.  Recent cases 
During  the  fact-finding  mission  different  stakeholders  mentioned  recent  cases,  covering 
2012 to 2016. Information on eight cases is presented below. 

Resignation of the Minister over an informal payment (2016)  
At  the  end  of  January  2016,  it  was  announced  that  the  Minister  of  Health  would  resign  in  relation  to  a 
corruption scandal: ‘Minister of Health admits that in the past she has given a bribe to physicians concerning 
an operation of her relative.46’ The former Minister revealed, during a radio interview, that approximately 10 
years ago she herself had paid a so-called ‘envelope’. Though it might be an accepted practice in society, 
offering a bribe is an illegal act punishable by law. Hence, after the Minister revealed this information, the 
Special  Investigations  Service  began  an  inquiry.  A  few  days  later,  the  Minister  announced  that  she  would 
resign.  

In  one  of  the  interviews  during  the  fact-finding  mission  we  briefly  touched  upon  the  case  regarding  the 
resignation of the former Minister of Health. The stakeholder emphasised that this Minister did not only leave 
because of the fact that she paid a bribe to a physician, but rather because of several conflicts with other 
people.  

Pre-trial investigation – Hospital’s public procurement procedures I (2015/2016) 
This  case  concerns  corruption  in  public  procurement.  There  was  a  widespread  corruption  scheme  in  place 
that favoured particular companies in public procurement in return for bribes that were being paid to high 
profile  officials  in  the  accused  hospital.  The  Executive  Director,  Strategic  Management  Director,  and  the 
Director  of  Infrastructure  of  the  hospital  were  arrested  on  suspicion  of  abuse  of  office  for  personal  gain, 
bribery as well a related/other crimes47. The case received considerable coverage in the press, including the 
following:  
- 

“A  politician,  ex  Member  of  the  Council  of  specific  municipality,  Ms  ‘X’  is  accused  of  alleged  fraud  and 
forgery which had allowed her to receive non lawful compensations. A Medic of the hospital and a medic 
of the central outpatient clinic that allegedly helped are also accused”;48 
“High profile officials of the accused county hospital are suspected of corruption including counts on abuse 
of  office  and  bribery.  Court  has  ordered  a  sworn  statement  not  to  leave  and  to  pay  bail  as  procedural 
measures”; 49 
“Corruption scheme in the Hospital’s pharmacy has been also allegedly involved. The director is suspected 
of trafficking influence”. 50 

- 

- 

Pre-trial investigation – Hospital’s public procurement procedures II (2016) 
Another  hospital  is  also  suspected  of  public  procurement  corruption.  “Special  Investigation  Service  of 
Lithuania  continues  investigation  on  bribery  during  the  public  procurement  procedures  in  the  Hospital.  As 
suspected, one clinics manager took a bribe from a company, which provides medical technics and tools. In 
another investigation the director of the Hospital is suspected of bribery and abuse of power during public 
procurement process concerning construction and medical technics. He has been suspended from the office 
for 9 months. In addition, another case has already reached the court – the accused is ex-deputy of the chief 
physician  of  the  hospital,  who  allegedly  took  a  bribe  and  made  favourable  conditions  for  one  furniture 
company”.51 As with the Hospital of the above described case, high level officials in the hospital are suspected 
of accepting/requesting bribes in return for favouring selected providers in the procurement procedures.  

Pre-trial investigation – improper marketing (2015-2016) 
One  stakeholder  briefly  mentioned  the  case  of  a  pharmaceutical  company  (which  is  part  of  a  larger 
international  pharmaceutical  group).  The  case  revolves  around  kickbacks  that  were  given  to  physicians 
promoting  a  certain  medicine.  11  employees  of  the  pharmaceutical  company,  suspected  of  bribery,  have 
been taken into custody by the Special Investigations Service. In addition, a number of physicians are under 
investigation. An interviewee mentioned that this is the first case ever where physicians will be prosecuted. 
Hence it may be an important case to send a signal that this behaviour will be punished.  

46 https://www.corruptioneurope.com/article/r-alaeviit-pripaino-pati-davusi-ky-medikams. 
47 http://www.delfi.lt/news/daily/lithuania/siauliu-ligonine-krecia-skandalas-stt-sulaike-
vadovybe.d?id=69399354. 
48 https://www.corruptioneurope.com/article/politik%C4%97-bus-teisiama-d%C4%97l-dokument%C5%B3-
klastojimo-nustatant-negali%C4%85. 
49 https://www.corruptioneurope.com/article/korupcija-%C4%AFtariamiems-%C5%A1iauli%C5%B3-
ligonin%C4%97s-vadovams-skirti-u%C5%BEstatai-daug%C4%97ja-%C4%AFtariam%C5%B3j%C5%B3. 
50 https://www.corruptioneurope.com/article/korupcines-iauli-ligonins-schemas-buvo-traukta-ir-vaistin-
kriminalai. 
51 https://www.corruptioneurope.com/article/stt-pradjo-dar-vien-ikiteismin-tyrim-dl-kyininkavimo-panevio-
ligoninje. 

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Updated Study on Corruption in the Healthcare Sector  

First two cases ever of physicians being convicted (2016) 
In 2016, two physicians were prosecuted and sentenced: 
-  A female physician was convicted for writing antedated sick leave notes. The Doctors’ Accreditation Agency 

revoked her license for a period of 1 year; 

-  A  male  physician  was  convicted  for  asking  for  informal  payments  for  injections  he  administered.  This 

physician’s licence has also been revoked for a period of 1 year.  

These were the first two cases of physicians being convicted, and the hope is that these convictions will serve 
as an example for other physicians and have a deterrent effect.  

3.3.7.  Recent policy developments 
Anti-corruption strategy  

In Lithuania, there are anti-corruption programmes in place at three levels: 

  The national (not healthcare specific) anti-corruption programme of the Special 

Investigation Service52; 

  The sector-specific anti-corruption programme of the Ministry of Health, which 

focusses on: 

-  Bribery in medical service delivery (informal payments); 
-  Public procurement; and 
-  Reimbursement of medicines. 
  Mandatory anti-corruption programmes at the level of healthcare institutions.  

Each programme consists of multiple action points, and the programmes of the institutions 
should be aligned with those of the Ministry of Health and the Special Investigation Service. 
The Ministry of Health and the Special Investigation Service closely cooperate with each 
other  and  with  the  institutions  in  the  fight  of  corruption.  The  results  of  the  Lithuanian 
Corruption Map 2016 indicate that the perception of 57% of the public is that the Special 
Investigations  Service  is  the  institution  most  likely  to  contribute  to  the  reduction  of 
corruption  (in  2014  this  was  only  43%).  Government  was  mentioned  by  50%  of  the 
population (53% in 2014). 

Several  stakeholders  have  expressed  concern  about  the  long  list  of  action  points  for  a 
relatively short implementation period and the apparent lack of focus. In addition, it was 
mentioned that particularly for healthcare institutions, it appears difficult to prioritise and 
set clear and measurable goals.  

The  Corruption  Map  2016  indicated  that  26%  of  the  citizens  had  heard  about  the 
implementation of corruption prevention and mitigation measures. Though it may appear 
a relatively low number, it is already substantially better than in 2014. When asked what 
measures  they  think  should  be  implemented,  the  front-runner  is  “penalties  tightening”, 
which is mentioned by 43% of the population.  

Policies and practices to prevent and control informal payments 

To reduce the risks for, and occurrence of, informal payments, different measures have 
been put in place. These are targeted at patients, medical professionals, and/or health care 
institutions.  

52 The full plan, as well as a summary of the main points, are available online: 
https://www.stt.lt/en/menu/corruption-prevention/anti-corruption-programmes/national-programme/#turinys.  

59 

 
 
 
 
 
 
 
                                                 
Updated Study on Corruption in the Healthcare Sector  

Policies and practices targeted at patients  

Different  measures  have  been  implemented  with  the  aim  of  increasing  the  information 
standards  for  patients  and  raise  awareness  about  the  issue  of  petty  corruption.  For 
example, by:  

  Providing a list of the services that are free of costs;  
  Providing access to health data through E-government so that they (patients) 
can  see  which  services  have  been  reimbursed  for  them  and  at  what  cost  (to 
date this is not used very frequently by patients); 

  Providing information on criminal liability;  
  Providing information on how to report corruption on the websites of both the 

Special Investigation Agency and the Ministry of Health; 

  Setting  up  two  dedicated  hotlines  for  whistleblowing  (one  at  the  Special 

 

Investigation Service and one at VLK);  
Implementing  an  address  of  the  CEO/director  of  healthcare  institutions 
consisting of both a written address as well as a verbal address (for example on 
a  screen  in  the  institution).  These  addresses  should  contain  certain  standard 
phrases  that  mention  for  example  “this  institution  does  not  tolerate  informal 
payments or gifts’’; 

  Developing targeted advertising campaigns; 
 

Implementing  IT  technologies  to  increase  transparency,  such  as  the  online 
waiting list for hip replacements. 

The Lithuanian Corruption Map 2016 reveals that reporting has increased, but it is still at 
the lower end; 23% of the citizens indicated that they know where to report corruption. 
One way to increase reporting may be by introducing additional whistleblowing systems 
that do not appear as formal as the ones at the Special Investigation Service and at VLK. 
For  example,  hotlines  could  be  set  up  at  the  level  of  the  healthcare  institution;  it  was 
suggested by a stakeholder that the opportunity to report to a manager of an institution 
might also reduce the barriers for reporting.  

Another policy proposal targeted at patients is the setting up of a fund were patients could 
deposit voluntary additional payments to physicians, thereby essentially trying to formalise 
the informal payments. The plan for this has, however, been dropped; there were too many 
concerns with regard to definitions and practicalities.  

Policies  and  practices  related  to  informal  payments  targeted  at  medical 
professionals 

Patients were the first target group of most anti-corruption measures, but now measures 
targeted  at  medical  personnel  are  also  being  implemented.  For  example,  a  behavioural 
code has been developed, in accordance with the United Nations regulations. In addition, 
a decree of the Ministry stipulates that at least 3 training sessions on ‘what to do about 
corruption’ should be organised for employees of healthcare institution. Training sessions 
on how to resist informal payments are in the pipeline. 

Another measure is the implementation of a new monitoring system for informal payments 
connected  to  the  dedicated  phone  line  where  people  can  report  instances  of  petty 
corruption.  The  number  of  calls  to  the  dedicated  phone  line  have  been  increasing  since 
2013.  Follow-up  on  reported  cases  of  corruption  is  therefore  conducted  either  by  the 
municipality or by the VLK, depending on the ownership of the particular institution.  

Policies and practices related to informal payments targeted at institutions  

Specific measures for institutions are also being put in place. For example, all institutions 
are required to introduce ISO quality standards. In addition, the plan is to also introduce 
ISO 3001 on bribery as a requirement. This ISO standard has been approved only recently 
(October 2016). As yet, not all institutions have these standards in place.  

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Updated Study on Corruption in the Healthcare Sector  

In  addition  to  the  prevention  measures,  there  are  also  control  measures  in  place  for 
institutions. An example of such a control measure is the ‘clean hands’ programme53. For 
this programme, all healthcare institutions are separately assessed based on criteria that 
have been introduced by a decree of the Ministry of Health. In this assessment institutions 
are graded and subsequently categorised in three categories: 

  Group 1: Transparent institutions; 
  Group 2: Candidates for Group 1; 
  Group  3:  Institutions  where  not  all  criteria  are  in  place  and  there  is  a  higher 

probability of corruption.  

No  information  is  available  on  the  exact  number  of  institutions  per  group,  but  several 
stakeholders mentioned that institutions are rising from group 3 to group 2 and that the 
number of institutions in group 1 is still  limited. The publication of the results gives the 
institutions clear indications on how to improve the current situation. The implementation 
of,  and  compliance  with,  this  programme  has  not  been  evaluated  and  hence  it  is  not 
possible to assess its impact. 

Policies and practices to prevent and control improper marketing 

Ban on gifts from sales representatives 

In  2014,  the  Ministry  of  Health  introduced  a  ban  on  gifts  from  pharmaceutical  sales 
representatives  to  physicians,  which  are  not  related  to  the  professional  activities  of  the 
physician. Before the introduction of this legislation, one would often see many sponsored 
items (such as chairs and stationary) in a physician’s office. As of 2014, this is no longer 
the case.  

Self-regulation by the pharmaceutical sector 

The pharmaceutical sector in Lithuania has put in place several self-regulation measures 
to prevent and control corruption including an ethical code and a disclosure code.  

The associations for innovative medicines (IFPA) and for generic medicines (VGA) jointly 
approved an Ethical Code for Pharmaceutical Marketing. The aim of this code is to “govern 
pharmaceutical marketing and relations with pharmaceutical professionals and healthcare 
professionals  as  well  as  relations  between  the  pharmaceutical  industry  and  patient 
organisations”.54 Furthermore, there is an Ethics commission in Lithuania, composed of 7 
members – one independent chairperson, 3 members delegated by IFPA and 3 members 
delegated  by  VGA.2  This  commission  has  members  with  financial  as  well  as  medical 
backgrounds. It is important to note is that there is a law in place which states that at the 
end of every year, each healthcare professional can choose whether they want to have a 
disclosure  or  not.  Hence,  healthcare  professionals  need  to  give  their  consent  to 
pharmaceutical companies for disclosure of the financial ties. 

The Disclosure Code a self-regulation measure in the pharmaceutical sector, according to 
which pharmaceutical companies have to disclose their payments for scientific events to 
physicians. The Disclosure Code is a common code for both IFPA and VGA and is followed 
by 40 companies. It is estimated that the percentage of personal disclosure in Lithuania is 
75%; this is higher than in all other CEE countries. This gives the impression that the Code 
has an impact, but this cannot be said with certainty however, as there has not (yet) been 
an evaluation of the impact of the implementation of the Disclosure Code. One problem for 
the (potential) effectiveness of the Code is that at the end of each year, physicians can 
choose  –  according  to  law  –  if  they  want  the  payment  to  them  disclosed  or  not. 
Pharmaceutical  companies  can  only  disclose  their  financial  ties  with  physicians  if  these 
physicians give consent for this. This may result in underreporting, a problem which was 

53 http://ec.europa.eu/europe2020/pdf/csr2016/nrp2016_lithuania_en.pdf.  
54 http://transparency.efpia.eu/countries/16/16/Lithuania.  

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also experienced by the Ministry of Health when, in 2014, they imposed a requirement on 
the industry - through the State Medicine Control Agency - to publicly provide information 
on the doctors that received funding from the pharmaceutical industry for scientific events. 
At that time, a substantial number of doctors refused to give consent for publishing their 
information.  

The Disclose Code is currently self-regulated, but the Ministry of Health is exploring the 
possibility  of  introducing  legislation  on  this.  The  pharmaceutical  sector  in  Lithuania 
encourages this development as it will lead to one common administrative approach and 
easier management. The Ministry of Health emphasised that in developing this legislation, 
it  is  important  to  take  note  of  how  information  should  be  provided  so  that  it  is 
understandable  for  the  general  public.  In  addition,  the  Ministry  of  Health  will  look  into 
potentially  expanding  the  scope  of  the  disclosures  to  include,  for  example,  also  clinical 
trials or other payments that were made by the industry. The pharmaceutical sector would 
like  to  see  this  legislation  be  implemented  for  other  healthcare  sectors,  e.g.  medical 
devices, as well. 

Other self-regulation initiatives in the pharmaceutical sector include: 

 

the  drafting  of  a  white  paper  together  with  the  medical  society  about  the 
interaction  and  collaboration  between 
the 
pharmaceutical industry (this paper is expected to be published in 2017); and  
  a framework agreement on collaborating with authorities: in 2014 a framework 
agreement  was  signed  between  the  pharmaceutical  industry  and  the 
government  with  the  aim  to  collaborate  in  a  transparent  way  and  to  develop 
principles regarding ethical conduct.  

the  medical  society  and 

Introducing Health Technology Assessment 

One  stakeholder  suggested  that  one  way  to  improve  the  allocation  of  resources  is  to 
implement Health Technology Assessment (HTA)55; it was noted that it was agreed already 
four years ago that HTA should be implemented, but that this has still not been done. The 
stakeholder mentioned that setting-up an HTA agency might not be feasible in Lithuania, 
given the lack of human resources. Nevertheless, a system of mutual recognition could be 
introduced. This in turn raises the question of which Member States would serve as good 
reference countries for Lithuania.  

Reimbursement of medicines 

On 1 January 2016, the medicine law regarding the reimbursement of drugs was amended. 
The  aim  was  to  make  the  process  more  transparent.  Amongst  other  things,  a  new 
reimbursement committee was established, consisting of representatives on behalf of the 
patient organisations, Ministry of Finance, Ministry of Social Affairs, Ministry of Health and 
representatives of the medical universities. A few stakeholders have expressed concerns 
with regard to the competence of this committee given the very broad background.  

Another transparency increasing measure is that the applicant has the possibility to listen 
to the voice recording of the meetings at the Ministry of Health. One stakeholder suggested 
that transparency would be further increased by making the meetings open to all interested 
parties.  

The impact of the increased transparency in the reimbursement process has not (yet) been 
evaluated and its effectiveness can therefore not be assessed.  

55 “Health technology assessment (HTA) is a multidisciplinary process that summarises information about the 
medical, social, economic and ethical issues related to the use of a health technology in a systematic, 
transparent, unbiased, robust manner. Its aim is to inform the formulation of safe, effective, health policies that 
are patient focused and seek to achieve best value.” (Source: EUnetHTA, 
http://www.eunethta.eu/faq/Category%201-0#t287n73).  

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Authorisation of pharmaceuticals - State Medicine Control Agency 

The State Medicine Control Agency deals, amongst other things, with the registration of 
medicines. The latest research on registration of medicines was conducted in 2013 and it 
was concluded that this is a complicated issue.  

The centralised procedure is highly regulated by the European Medicines Agency (EMA). 
The aim of the State Medicine Control Agency is to design the national procedure in such 
a way that it is clear and transparent. An example of how this is implemented is the new 
procedure in which all the notes, also the expert notes, only have to be provided once. The 
selection of the members of the scientific committees – the participants in the registration 
procedure - is being done on the basis of the rules set out by EMA and all members yearly 
have to declare their private interests. Another measure regarding transparency is that the 
minutes of all the meetings of the scientific committee have been made public. Moreover, 
there is a procedure of appeal that pharmaceutical companies can use when they do not 
agree with the decision.  

There is also a programme in place for assessing the probability of corruption occurring. 
There  are  yearly  evaluations  of  compliance.  Each  year  a  survey  is  conducted  amongst 
participants and they are given the opportunity to signal any drawbacks. Moreover, internal 
audits are conducted. On the basis of the results of the evaluations, surveys, and audits, 
corruption probability is introduced into the action plan of the Agency. 

3.3.8.  Challenges and conclusions 
Lithuania is very active in the field of anti-corruption. Anti-corruption programmes have 
been implemented on three levels: the national level, the healthcare sector level, and the 
health institution level. Most of the implemented measures focus on creating awareness 
and increasing transparency. One of the challenges with this broad multi-layered approach 
is  to  create  sufficient  focus  and  measurable  Key  Performance  Indicators  (KPIs). 
Unfortunately, hardly any of the implemented policies and practices have been evaluated 
properly;  this  does  not  seem  to  be  a  priority  and  there  are  (almost)  no  funds  made 
available for this. As a result, it is difficult to assess the impact and effectiveness of the 
efforts made in the fight against corruption. 

Results  of  national  surveys  indicate  that  the  perception  of  citizens  is  that  healthcare 
institutions are  the  most  corrupt  public  institutions  and that  corruption  has  increased  in 
recent  years.  At the  same  time,  these  surveys  also  show that the  percentage  of  people 
believing that corruption has increased is substantially lower than a few years ago and that 
also  the  number  of  people  making  informal  payments  has  been  decreasing.  However, 
although some progress seems to be made, petty corruption remains a big challenge for 
Lithuania. This is largely due to the general acceptance of making informal payments by 
society. The Ministry of Health and VLK are putting a lot of effort into providing patients 
with  higher  information  standards  and  opportunities  for  reporting  petty  corruption.  In 
addition, measures for healthcare professionals and institutions are being put into place. 
Interestingly, while all stakeholders agree that the low wages for physicians is one of the 
main  risks, this has not  yet  been  addressed.  In  addition to  preventative  and  awareness 
raising measures, systems for whistleblowing are being set-up, and this year for the first 
time ever two physicians have been convicted for bribery in medical service delivery – the 
hope is that this will have a deterrent effect. Citizens have said that they consider tighter 
punishment  an  important  measure,  so  (high  media  coverage  of)  prosecution  and 
convictions of physicians may be an important step in the right direction.  

A positive development is that it seems that the mind-set of the Lithuanian public is slowly 
changing;  the  new  generations  of  both  physicians  and  patients  are  publicly  outspoken 
against informal payments and do not accept it nor consider it common practice. This is 
confirmed  by  data  about  the  acceptance  and  willingness  to  pay  bribes  in  general:  the 
Lithuanian Corruption Map 2016 reveals that the percentages of residents who believe that 

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bribery  helps  to  solve  problems  and  actually  who  pay  a  bribe  to  solve  the  problem 
decreased from 75% to 68% and from 68% to 40%, respectively, between 2008 and 2016. 

As  mentioned  in  the  recent  publication  on  Health  Care  and  Long-term  Care  Systems  & 
Fiscal Sustainability (2016), additional measures to incentivise good prescription practices, 
monitor prescription of drugs as well as outlining a clear policy on generics, combined with 
price  regulation  and  direct  expenditure  control  should  be  considered.  These  can  be 
expected to have a beneficial effect on combating petty corruption. This also holds for the 
recommendation to improve data collection and monitoring of the entire healthcare process 
(inputs, processes, outputs, and outcomes).  

As  stated,  petty  corruption  remains  an  important  challenge  for  the  country,  but, 
increasingly,  more  focus  is  being  directed  to  the  corruption  in  public  procurement; 
estimations indicate that a significant amount of money is lost to this form of corruption 
each year. Lithuania has a central procurement system in place, and the Ministry of Health 
tries  to  encourage  institutions  to  use  this  system  more  frequently  and  to  make  joint 
purchases.  

With regard to improper marketing, several self-regulation initiatives are in place in the 
pharmaceutical sector, including a Disclosure Code. This code will potentially be changed 
into  a  law  and  made  applicable  for  other  sectors  within  the  healthcare  system  as  well. 
Other legislation that is currently lacking, but mentioned as a priority by the minister, is 
that on lobbying. While the Ministry of health acknowledges that lobbying is not necessarily 
a problem, it is important to properly regulate it to avoid corrupt practices.  

To conclude, although the problem of corruption is still widespread, attitudes are slowly 
changing;  the  generational  shift  seems  to  be  accompanied  by  a  growing  intolerance  for 
corruption. Moreover, many policies and practices have been implemented in recent years 
and it seems that significant progress has been made in the fight against corruption in the 
healthcare  sector.  However,  given  the  lack  of  systemic  evaluations  of  the  implemented 
policies and practices, crucial information pinpointing what has worked and why (not) is 
lacking. 

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3.4.  Hungary 

3.4.1.  Overview/summary 
The  research  trip  to  Budapest,  Hungary,  took  place  from  23  –  25  January  2017.  Five 
interviews  with  stakeholders  from  different  categories  were  undertaken  in  person.  An 
overview can be found below. 

Table 3.13 Overview of interviewees 

Date 

Organisation  

23/01/2017 

23/01/2017 

24/01/2017 

- 

- 

- 

Stakeholder category 

National Competent Authority 

Academic 

Patients 

02/02/2017 

Transparency International Hungary 

Anti-corruption NGO 

25/01/2017 

Minister of State for Health 

Regulator 

Note: please mark in red the information for which the interviewee has not given explicit consent for publication.  

3.4.2.  General description of the healthcare system 

Organisation 

Hungary has a single-payer health insurance system with (virtually) universal coverage, 
and has achieved a successful transition to a purchaser–provider split model, away from a 
previously  (over-)  centralised,  integrated  ‘Semashko-style’  system.56  New  payment 
methods  that  create  incentives  for  increased  technical  efficiency  have  been  introduced, 
such as the DRG-based payment system for hospitals that was adopted in 1993 and with 
which Hungary has accumulated a wealth of experience. 

The  National  Health  Insurance  Fund  (NHIF)  was  the  most  important  national  pool  of 
financing  in  healthcare.  In  2017  the  NHIF  was  integrated  into  the  Ministry  of  Human 
Capacities, and renamed as National Institute of Health Insurance Fund Management (or 
NEAK in Hungarian).57  

Health insurance for Hungarians is mandatory, and the system is based on the provider 
payment  model,  which  has  become  more  output-based.  Family  doctor  services  are  paid 
through capitation, while outpatient specialist care is funded through a fee-for-service point 
system. DRGs are used for acute inpatient services, and chronic care is funded through 
per diem rates.58 

Municipalities are responsible for primary health care. The responsibility for secondary and 
tertiary care provision is shared among municipalities, counties, the central government, 
and private providers. There are substantial regional disparities in the provision of / access 
to services. 

Table 3.14 Responsibility for different parts of the healthcare sector 

Level of care 

Responsibility 

Family doctors / General Practitioners (GPs) 

Out-patient clinics 

Hospitals 

University clinics and medical centres 

Local  

Local  

National 

National 

56 See the Health Systems in Transition profile of Hungary for this section, to be found online at 
http://www.hspm.org/countries/hungary25062012/livinghit.aspx. 
57 OECD Health at a Glance Europe (2016), http://www.oecd.org/health/health-at-a-glance-europe-
23056088.htm. 
58 Gaál P, Szigeti S, Csere M, Gaskins M, Panteli D. (2011), Hungary: Health system review. Health Systems in 
Transition, 13(5):1–266. 

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Updated Study on Corruption in the Healthcare Sector  

Financing 

Public  health  expenditure  is  financed  through  a  combination  of  contributions  and  tax 
revenue  transfers,  with  the  latter’s  importance  increasing.  Family  doctors  act  as 
gatekeepers generally, but only have a weak gatekeeping role and some specialist services 
can be accessed without a referral. 

The  NEAK  is  responsible  for  the  financing  of  new  innovative  medicines  through  its 
Reimbursement Department. Health technology assessments (HTAs) are mandatory, and 
are  conducted  by  the  National  Institute  for  Quality  and  Organisational  Development  in 
Health  Care,  which  uses  the  formula  (2 – 3x  Gross  Domestic  Product  (GDP)  per 
capita/Quality Adjusted Life Year (QALY)) as a soft reference point.59 

In  response  to  the  crisis,  the  Hungarian  government  reduced  the  publicly  reimbursed 
benefits package – mainly temporary sickness benefits. 

In  2015  there  were  several  demonstrations  about  the  underfunded  health-care  system. 
The  underfunded  health-care  system  creates  in  two  problems.  Firstly,  large  numbers  of 
medical professionals take jobs abroad, and secondly, there have been problems with the 
supply  of  medicines  (which  seem  to  have  been  addressed).  This  all  contributes  to  a 
situation  in  which  hospitals  have  a  more  difficult  time  to  provide  care  of  the  highest 
standards for their patients.  

Hungarian health  care  workers  earn  one-tenth as  much as  health  care  workers  in  other 
Western  countries,60  health  care  facilities  cannot  provide  the  minimum  number  of 
personnel necessary to run the facility and patients’ health is jeopardized.  

Table 3.15 Indicators of the healthcare system in Hungary 

Indicators of the healthcare system 
Financing of the healthcare system (1) 

2012 

7.5% 
65.5% 
2.7% 
29.1% 

2015 (or 
nearest year) 
7.0% 
67.0% 
2.7% (2013) 
28.1% 
(2013) 

EU 
average 
10% 
77.8% 
2.2% 
15% 

Tax-based 

Total health expenditure as % of GDP 
Public expenditure as % of total health spending 
Private insurance as % of total health spending (EC)61 
Private-out-of-pocket as % of total health spending  

Organisation of the healthcare system (2) 
Social insurance or tax-based system? 
Gatekeeping by a general practitioner (GP)? 
How are physicians paid? (e.g. salary, fee-for-service, 
capitation) 
Patient organisation involvement (3=good, 
2=intermediary, 1=not-so-good) 
Accessibility (3=good, 2=intermediary, 1=not-so-good) 
Family doctor same day access 
Major surgery < 90 days 
Cancer therapy < 21 days 
CT scan < 7 days 

59 Source: WHO (2014), Eurohealth incorporating Euro Observer. Volume 20:2. Online to be found at 
http://www.euro.who.int/__data/assets/pdf_file/0017/252251/EuroHealth_v20n2.pdf?ua=1.  
60 See Budapes Beacon (March 5th, 2015), Hungarian health care workers earn 1/10th that of their western 
counterparts ‘’, last consulted 25 July 2017 at http://budapestbeacon.com/public-policy/hungarian-health-care-
workers-earn-110th-that-of-their-western-counterparts/20371. In this article Western European countries are 
Germany, England or Sweden. Note: these are not purchasing power pairty (PPP) numbers and so do not take 
into account the cost of living. 
61 European Commission (2016), Joint Report on Health Care and Long-Term Care Systems and Fiscal 
Sustainability, http://ec.europa.eu/economy_finance/publications/eeip/ip037_en.htm.  

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Updated Study on Corruption in the Healthcare Sector  

Sources: (1) OECD Health at a Glance Europe (2016), OECD ‘Health expenditure indicators’ DOI: 10.1787/data-
00349-en,  Health  at  a  glance  (2015)  DOI:10.1787/health_glance-2015-graph156-en,  Eurostat  healthcare 
expenditure by financing agent, (2) World Bank healthcare statistics and underlying data for indicators, Eurostat 
healthcare  statistics  and  underlying  data  for  indicators,  European  Commission  (2016),  Joint  Report  on  Health 
Care and Long-Term Care Systems and Fiscal Sustainability. 

Table 3.16 Corruption in healthcare perceptions in Hungary 

Corruption in healthcare perceptions  
Do you think that the giving and taking of bribes, and the abuse of positions of power 
for personal gain, are widespread among people working in the public health sector?  

(% of respondents agree - Eurobarometer) 

50% 

56% 

2011* 

2014** 

EU 
average** 
33% 

Sources: * Special Eurobarometer 374, table QC4 (fieldwork September 2011); ** Special Eurobarometer 397, 
2014 (fieldwork February  -  March 2013);  own research  (fieldwork  February/March 2013). No new  information 
was found in the Eurobarometer of 2013. 

Table 3.17 Corruption Perception Index (CPI), Hungary 

Corruption Perception Index 

Score 

Rank 

2016 

48* 

57*** 

Source: www.transparency.org; * CPI score is based on a scale ranging from 0 to 100, a score of 0 indicates a 
country is perceived as very corrupt and a score of 100 indicates a country is perceived as very clean; ** the 
2012 CPI ranked 174 countries, where a lower rank indicates a cleaner country; *** the 2016 CPI ranked 176 
countries, where a lower rank indicates a cleaner country.  

3.4.3.  General perception of corruption 
Hungary has moved down on the Transparency International (TI) corruption list of 2015, 
which indicates that Hungary is one of the most corrupt countries in Europe. Only Romania 
and Bulgaria performed worse in the EU.62 A recent TI survey (published November 2016) 
showed a declining willingness to file reports with the relevant authorities for suspected 
corrupt practices. Although young people are seen to be more willing to step up against 
corruption, only 14% of all respondents said they believed average people can act against 
corruption.63  

Risks and obstacles 

The Hungarian government under Orbán, on 7 December 2016, withdrew from the Open 
Government Partnership, a multilateral pro-transparency agency, citing bias in favour of 
NGOs and against government responses as the reason.64 

The  Hungarian  Ombudsman  is  independent  and  the  judiciary  also  acts  independently. 
However, in recent years the healthcare specialists at the Ombudsman have become less 
visible,  i.e.  it  is  not  known  to  the  public  who  these  person(s)  is  (are).  Moreover,  the 
procedure for filing complaints with the Ombudsman has been made more onerous, so that 
it has become more difficult to directly reach the Ombudsman: for many issues you have 
to go through the State.  

62 See http://index.hu - Hungary corruption health news. 
63 See http://bbj.hu/economy/hungarians-see-corruption-worsening-ti-survey-says_124852.  
64 See http://bbj.hu/politics/hungarian-govt-quits-pro-transparency-organization_125900.  

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The  representative  of  the  patient  rights’  body  is  now  also  a  member  of  the  Ministry  of 
Human Capacities, even though it is by law required to be independent (ACT CLIV/2017 
on Healthcare).  

A vice president of the governing party recently declared that NGOs are ‘foreign agents’ 
that need to get out of Hungary.65 NGOs need to declare their financial statutes and show 
where their funding came from, even though this information is, for the majority of NGOs, 
already publicly available on their websites. 

In the past, the Hungarian national government had formalised consultation with medical 
professionals,  trade  unions,  patient  organisations  and  local  governments,  under  the 
National Health Council (NHC). This had an elected president and two vice-presidents, one 
of which needed to be a patient representative. The NHC functioned as an advisory council 
to the government. The NHC was abolished when the Ministry was reorganised in 2010, 
because the Minister saw it as no longer relevant. 

Over the last few years, the State Secretary for Health has regularly been replaced. Many 
healthcare policy changes are not clearly communicated in official media, and the media 
that ask questions are very weak. The general population therefore does not ‘see’ what is 
changing in terms of healthcare policies, much less sees a reason to protest. 

There  are  signs  that  informal  pressure  is  exerted  on  certain  national  associations,  to 
prevent them from directly communicating on healthcare issues to the press without prior 
approval from the State Secretary.  

3.4.4.  Types of healthcare corruption 
The Special Eurobarometer 397 on anti-corruption showed that some 19% of Hungarians 
feel they are affected by corruption in their daily  life, and 89% of the population thinks 
corruption is widespread in their country.66 Furthermore, 10% of Hungarians (stated that 
they)  had  to  give  an  extra  payment  or  valuable  gift  to  a  nurse  or  physician  (or  other 
donation) to the hospital in order to receive treatment. 67  

This is the highest rate in Europe after Romania, Latvia, and Greece. Of those who indicated 
they had to give an extra payment, 32% indicated they did so before the care was given, 
47% after the care was given, 7% indicated the physician or nurse directly asked for an 
extra  payment/gift  in  advance,  and  9%  indicated  that  they  were  asked  to  pay  for  a 
privileged treatment.68 

The  study  team  also  spoke  with  the  State  Minister  for  Healthcare  on  the  state  of  the 
Hungarian  healthcare  system.  Because  of  his  background  as  a  healthcare  manager,  the 
Minister of State’s approach to (reforms of) the healthcare system is different compared 
to his predecessors. He usually transposes best practices from other sectors into the health 
sector, convinced that the health sector could benefit from them.  

In  an  effort  to  promote  data-driven  policymaking  in  healthcare,  the  Minister  of  State  / 
Ministry has been looking at the utilisation of healthcare by households, i.e. at the micro-
level.  This  showed  them  how  much  healthcare  was  consumed  by  the  population, 
irrespective of which institution provided the healthcare services. The data came from the 
database  of  the  Hungarian  National  Health  Fund.  This  was  the  first  time  the  data  was 
analysed from the user-perspective.  

65 See The Guardian (13 January 2017), Hungary defends planned crackdown on foreign-backed NGOs. To be 
found online at https://www.theguardian.com/world/2017/jan/13/hungary-defends-planned-crackdown-on-
foreign-backed-ngos. 
66 See Special Eurobarometer 397, http://ec.europa.eu/public_opinion/archives/ebs/ebs_397_en.pdf. 
67 See Special Eurobarometer 397, http://ec.europa.eu/public_opinion/archives/ebs/ebs_397_en.pdf.  
68 Multiple answers could be indicated per respondent. 

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It turned out that there were large differences between the smallest and the largest health 
care consumers: a factor of three for the consumption of in-patient care, a factor of five 
for out-patient care, and a factor of eight for chronic care. This is an indication that the 
actual consumption of health care is not determined by the needs of the population but by 
the needs of institutions (i.e. practice variation).  

Data  about  quality  of  care  are  not  systematically  collected,  which  is  perceived  as  being 
problematic.  As  a  result,  there  are  no  quality-related  incentives.  When  you  drill  down 
through the data to analyse them, it is very obvious how institutions are making an effort 
to offset their losses for certain procedures with other, profitable procedures. 

Transparency of data 

An  electronic  healthcare  system  will  be  put  in  place  in  November  2017,  through  which 
patients  will  be  able  to  retrieve  information  on  what  has  happened  to  them,  and  what 
funding  was  attached  to  those  procedures.  They  will  be  able  to  see  all  the  invoiced 
procedures.  Although  no  further  details  were  available  to  the  researchers,  from  the 
perspective  of  transparency,  this  would  be  a  major  step  forwards.  However,  every  step 
towards reforming the current system may weaken the position of the Minister of State, 
because hospital directors and other powerful actors in the system are not interested in 
doing this. 

The  department  of  Health  will  introduce  a  unified  basic  data  sheet,  which  every  GP  will 
have  to  use,  to  survey  and  assess  the  population  of  every  GP  practice.  The  intended 
duration  for  this  (self-)  assessment  is  three  years.  Currently,  different  suppliers  have 
different (electronic) data sheets. In the new situation, all GPs and hospitals will use the 
same data sheet. It will be a cloud-based approach, and the pilot phase is closing. On the 
1st of November every state-owned hospital which has a license of operation and is funded 
by  the  state,  will  have  to  participate  in  using  this  unified  data  sheet.  In  the  next  year, 
every private practice will also have to join this system if they want to keep their licenses. 
(Private practice currently still only represents a small share, approximately 2-3%, of the 
healthcare system, and is mostly focused on cosmetic surgery).  

On the 1st of November, all practices will have to retrospectively upload the information 
from  the  past  5  years  into  the  cloud,  which  will  mean  10  million  in-patient  records  and 
almost 100 million out-patient records. The question is how to protect this data from third 
parties.  The  personal  information  is  owned  by  the  patient,  but  after  the  data  has  been 
processed and anonymised it is owned by the government. 

Communication of healthcare reforms to citizens 

Awareness about the intended increase in transparency (via e.g. electronic patient dossier, 
electronic procurement) is not actively communicated at present. To some extent, this will 
revolve around the introduction of electronic identity cards, through which citizens will be 
able to retrieve their medical dossier as well. This is a new development. Patients will be 
able  to  see  the  procedures  that  are  invoiced  by  healthcare  professionals  as  well  as  the 
funding involved. Separately, with regard to the quality of care indicators, in the recent 
months  hospitals  have  been  motivated  to  publish  about  these  issues  by  the  (political) 
opposition  parties.  The  Minister  of  State  thinks  this  will  have  raised  awareness  among 
citizens as well. 

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Informal payments 

The distribution of informal payments is very skewed, as it is mostly the head physicians 
who  receive  these  payments.  About  60%  of  all  informal  payments  go  to  5%  of  all 
physicians.69 The younger generation receive less informal payments, and also does not 
want to rely on them. As a consequence, younger healthcare professionals often go work 
abroad.  This  is  particularly  relevant  for  nurses;  whose  wages  are  low  and  who  do  not 
benefit from the informal payments at all. 

In  many  studies  the  main  reason  to  justify  informal  payments  is  that  healthcare 
professionals’ salaries are too low. As it is, the healthcare sector ‘survives’ through informal 
payments. As the EU Anti-Corruption report (2014) highlighted,70 a law prohibits informal 
payments before treatment, but it is allowed when given after treatment has taken place.71 
There is a separate clause in the labour law prohibiting ‘gratitude’ payments, but this can 
be  (legally)  overruled  by  the  director  of  a  hospital,  whose  formal  approval  removes  the 
prohibition.72 

Double practice 

Double  practice  is  allowed  in  Hungary,  and  most  physicians  engage  in  it.  Although  no 
update has been made for all the 2013 study’s data, it is clear that 50% of patients make 
an informal payment for hospitalisation (with an average worth of 100 EUR), and 20% of 
patients make an informal payment worth 15 EUR for physician visits.73 Under this study, 
one specific area has been more closely examined: informal payments and double practice 
in delivery and maternity care.  

In Hungary, most women choose a specific physician for the delivery of their baby. Some 
of the physicians steer patients to private practice for pre-natal care, while delivery may 
be  steered  towards  a  public  hospital.  Women  want  to  deliver  their  babies  with  their 
physician present, which is the main motivation for informal payments as this would not 
fall under the traditional duties of a physician. 

The quality of care has been compared for those women who choose their physician and 
those who do not. Women who chose their physician felt much more satisfied and felt they 
were  treated  with  more  respect.  However,  the  ‘chosen’  physicians  appeared  to  perform 
much more interventions, many of which might not have been necessary and could even 
be  potentially  harmful.  Informal  payments  may  offer  an  explanation  for  this  situation. 
Physicians  feel  they  need  to  justify  why  they  are  present,  which  they  can  do  through 
performing an intervention – they can for example induce birth or perform a caesarean. 

The  Minister  of  State  for  Healthcare  has  noted  that  the  large  outflows  of  healthcare 
professionals  make  taking  legislative  actions  precarious.  Introducing  double  practice 
legislation would be a challenge, as Hungary is well-connected to the rest of Europe and 
the physicians would all leave for London if they saw a substantial dip in their salaries. 

69 See Gaal P, Evetovits T, McKee M. (2006), ‘Informal payment for health care: evidence from Hungary’. In 
Health Policy 77(1):86-102. 
70 See EU Anti-Corruption report (2014), Hungary chapter: p.13. To be found online at 
https://ec.europa.eu/home-affairs/sites/homeaffairs/files/what-we-do/policies/organized-crime-and-human-
trafficking/corruption/anti-corruption-report/docs/2014_acr_hungary_chapter_en.pdf. 
71 See the Criminal Code, section 291 (1), criminalising the acceptance of a promise of a payment. 
72 See the Labour Code, section 52 [2012. évi I. törvény a munka törvénykönyvéről] 
http://net.jogtar.hu/jr/gen/hjegy_doc.cgi?docid=A1200001.TV.  
73 See Baji P., Pavlova M., Gulácsi L., Farkas M., Groot W. (2014), The link between past informal payments 
and willingness of the Hungarian population to pay formal fees for health care services: results from a 
contingent valuation study. In European Journal of Health Economics 15(8): 853:67. 

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Public procurement 

The  main  areas  of  corruption  are  public  procurement  and  EU  funds  projects.  TI  has 
calculated that public procurement procedures are 20 – 25% more expensive than they 
should be because of corruption.74 As a result, every Hungarian citizen pays EUR 130 extra 
per year for public procurement. 

Access to information on fraud with EU funds is restricted to what is made available by the 
European  Commission  (EC),  the  European  Anti-Fraud  Office  (OLAF)  and  the  Hungarian 
government. According to TI Hungary, fraud with these funds goes back at least 10 years 
and  must  have  been  present  since  Hungary’s  accession  to  these  funds.  It  is  difficult  to 
judge,  because  the  first  full  cycle  of  EU  funds  programming  that  Hungary  was  part  of 
started in 2007, and the results of this cycle are only now emerging.  

As stated, public procurement (by hospitals) has been centralised. This is not necessarily 
an improvement, as transparency about the process has not increased accordingly. Health 
Technology  Assessment  (HTA)  reports  for  expensive  drugs  are  not  made  public  either, 
although  this  is  the  case  in  many  countries.  Overall,  it  is  not  clear  how  procurement 
decisions are made.  

Since the current government came into power the institutional set up of organising the 
use of these funds has been centralised. In TI’s view, it is probable that the quantity (size) 
of corruption has not changed, only the quality (or institutional level). Whereas previously 
corruption originated mainly at the level of local government, now all projects are overseen 
by the Prime Minister’s office (central level).  

3.4.5.  Recent cases 
On  January  4th  2016,  781  Hungarian  health-care  professionals  protested  against  the 
government’s  inadequate  response  and  efforts  to  combat  corruption  in  hospitals,  and 
demanded  substantially  increased  wages.  The  medical  professionals  also  asked  the 
Hungarian citizens to cooperate and send an email to the Ministry in the interest of ‘moving 
health-care forward’.75 In more recent protests (May 2017), pro-EU protesters united under 
the  banner  of  ‘Momentum’  demanded  more  government  accountability  and  improved 
healthcare.76 

Recently  an  oncologist,  who  was  sentenced,  was  in  the  news;77  he  received  informal 
payments  but  also  broke  ethics  rules  by  not  even  telling  some  of  his  patients  that  they 
were going to die soon, in order to receive more informal payments from them. One patient 
refused, and took him to court. In first instance, this physician was convicted, but in higher 
court his punishment was reduced. The court argued that the physician was an important 
specialist whose expertise was needed to help Hungarian society. His colleagues supported 
the professionalism of the physician. This case is now under arbitration by the third and 
highest level of the court. 

As  indicated  by  representatives  from  patient  organisations,  there  are  two  aspects  that 
patients  share  stories  about:  waiting  lists  for  orthopaedic  treatment,  for  example,  and 
access to new and expensive oncology drugs. There is strong governmental pressure to 

74 See TI factsheet on public procurement corruption, https://transparency.hu/wp-
content/uploads/2016/02/Public-Procurement-Corruption.pdf.  
75 See http://budapestbeacon.com/featured-articles/rtl-klub-names-maria-sandor-person-of-the-year-in-
hungary/30474.  
76 Se https://www.theguardian.com/world/2017/may/01/hungarians-send-message-to-orban-in-march-
supporting-european-union.  
77 See http://nepszava.hu/cikk/1135381-dontottek-nem-praktizalhat-a-rakos-betegektol-penzt-kikovetelo-
nogyogyasz and http://hvg.hu/itthon/20170520_magyar_orvosi_kamara_halapenz_etikai_eljaras.  

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reduce the budget for these oncological drugs, which reduces their availability to the public 
and with that restricts access for patients. An open letter by various patient organisations 
was recently sent to the Prime Minister, in which the risks of this issue were flagged.78  

Additionally,  there  is  a  Hungarian  corruption  database  where  press  articles  can  be 
searched: http://adatbazis.k-monitor.hu/index.html.  

Public procurement 

The Economic Competition Office (GVH) has imposed penalties on a few Budapest-based 
hospitals – they informed in a consortium to buy pharmaceuticals. The idea was to make 
the pharmaceuticals cheaper through larger volumes. This led to 2.5 billon HUF of savings. 
However,  in  a  criminal  proceeding,  emails  from  a  lawyer  appointed  by  pharmaceutical 
companies were intercepted which showed that the process was organised [corrupted], as 
the  pharma  companies  reconciled  their  prices  during  the  procurement  process.  The 
economic  GVH  imposed  a  fine  of  more  than  840.000  EUR  on  these  companies.  79  The 
Minister of State indicated this is only the tip of the iceberg; nevertheless a start has been 
made. The government has shown its resolve, and indicated in which direction it intends 
to go. 

One smaller case related to public procurement in a hospital. This related to a suspicion of 
corruption  in  public  procurement  of  medical  devices  (CT,  MR)  in  hospitals.  In  this  case, 
there  was  little  to  no  competition  and  prices  were  high,  with  a  total  value  of  30  billion 
HUF.80  

Quality of healthcare 

Just before Christmas 2016 a story broke that a dead body had been found in one Budapest 
hospital, which had already been there for two days. However, to date this incident had 
not led to any consequences for the hospital. The hospital has publicly stated that, because 
they outsource their cleaning work, this is not the responsibility of the hospital. Although 
not necessarily representative of the entire healthcare system, it is indicative of how overall 
quality controls and checks in the current system can be lacking. 

3.4.6.  Recent policy developments - healthcare 
In 2010, Fidesz became the governing party and some ministries were reorganised. As a 
result,  there  is  no  separate  Health  Ministry  anymore:  it  resides  under  the  Ministry  for 
Human Capacities. 

Since then, there have been a number of institutional changes in Hungary. As of January 
2017, the National Health Insurance Fund (NHIF) has been reorganised and now falls under 
the State Secretary for Health, whose cessionary is the Ministry of Human Capacity.81 This 
is  in  line  with  a  more  general  tendency  towards  centralisation.  This  can  be  seen  in  the 
hospital sector where responsibility for ownership rights has moved from the local to the 
national level. Public procurement (for hospitals) has also been centralised. 

78 See http://pharmaonline.hu/cikk/betegszervezetek_nyilt_levele_lazar_janosnak [Hungarian].  
79 Hungarian Competition Authority (2016), ‘Press Release. The GVH imposed fines for coordination of bids in 
tenders of hospitals’. Last consulted 13 February 2017 at 
http://www.gvh.hu/en/press_room/press_releases/press_releases_2016/the_gvh_imposed_fines_for_coordinat
ion_of_bids_in_.html. 
80 See http://nepszava.hu/cikk/1092529-hadhazy-ujabb-leleplezese---korrupcio-az-egeszsegugyben 
[Hungarian]. 
81 See http://medicalonline.hu/eu_gazdasag/cikk/itt_a_a_megszuno_hivatalok__hatterintezmenyek_listaja 
[Hungarian].  

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Healthcare expenditure 

The  OECD  statistics  (2015)82  on  Hungary  show  that  expenditure  on  healthcare  has  not 
increased over the past years (it is currently 7% - well below the OECD average – 9%), 
and  may  have  even  slightly  decreased  as  a  percentage  of  GDP.  Even  compared  to 
neighbouring countries, the share of public expenditure on health care in Hungary is the 
lowest.  It  is  worrying  that  the  share  of  out  of  pocket  expenditures  is  increasing  (at  the 
moment about one third of the total expenditure), as this means more of the burden falls 
on  citizens.  This  relates  mostly  to  co-payments  for  pharmaceuticals  (70%),  informal 
payments, and private sector services (whose share is increasing). 

Transparency 

In recent years many improvements took place at the NHIF that increased transparency.83 
They published more data and made these available on-site. The website was renewed, 
statistical  yearbooks  were  accessible,  and  even  some  contracts  were  made  public.  The 
NHIF  database  had  become  accessible  for  academic  researchers,  and  joint  research 
projects had started between universities and the NHIF. 

The NHIF was collecting data from all the providers, and reimbursement was based on this 
data.  As  the  NHIF  was  abolished  in  January  2017,  some  tasks,  such  as  handling  cash 
benefits  were  delegated  to  the  pension  funds.  Other  tasks  (e.g.  reimbursement  of 
providers)  remained  at  the  same  institute  under  the  same  infrastructure  but  under  a 
different Hungarian name. It is difficult to judge what the changes mean for quality of care. 
As for providers, a new public hospital is planned to be built in Budapest, but one can see 
that more and more private clinics are appearing as well.  

Waiting lists 

In 2012 the government introduced legislation that made the introduction of waiting lists 
mandatory across the country. Five years later, waiting lists have decreased. OECD studies 
indicate that regarding waiting lists, Hungary is in the 2nd, 3rd or 4th position for some of 
the procedures  (for  example,  hip  or  knee  replacements, although not for  access  to  new 
and innovative medicines). For one procedure, a waiting list that used to be 70,000 patients 
now  stands  at  28,000;  each  year  180,000  surgeries  are  performed.  This  means  the 
capacity is about six times bigger than the waiting list, which ensures that hospitals are no 
longer in a position to dictate to the government in the old way – blackmail or extortion, 
through raising public outcry.  

3.4.7.  Recent policy developments – corruption 
No evidence has been found that the situation has changed since 2013. Informal payments 
are still an important issue, as there are less public resources in the system. There was an 
initiative  for  residency  training  for  physicians,  who  could  receive  an  extra  scholarship  if 
they  signed  an  anti-corruption  statement.84  This  initiative  led  to  some  controversies,  as 
the younger people earned more than older people. 

82 See OECD Health Statistics 2015, to be found at https://www.oecd.org/els/health-systems/Country-Note-
HUNGARY-OECD-Health-Statistics-2015.pdf.  
83 From Health Systems in Transition (HiT) profile of Hungary: ‘There is a unique patient identification system 
that provides information on pharmaceuticals consumption and use of specialist inpatient and outpatient 
services at the level of individual patients. This is a rich, integrated data set. However, the government is not 
(yet) asking for health-policy related research from academia’. See 
http://www.hspm.org/countries/hungary25062012/livinghit.aspx. 
84 See http://www.edupress.hu/index.php/felsooktatas/222-havi-tamogatast-kapnak-a-frissen-szakvizsgazott-
orvosok [Hungarian]. 

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The  perception  of  most  Hungarian  health  care  consumers  towards  informal  payments  is 
that they are ‘inevitable due to the low funding of the health care system’ (Baij, Pavlova, 
Gulácsi & Groot, 2013).  

Anti-corruption training 

There is a specialised course for public procurement lawyers, which contains a module on 
preventing corruption. This course included examples of instances where members of the 
public objected to informal payments being termed corruption. In addition, there are ethics 
classes at Medical Universities, which include anti-corruption. However, TI is not aware of 
targeted anti-corruption classes at Medical Universities. 

Informal payments 

The  Medical  Chamber  has  adopted  ethics  rules,  which  have  a  long  section  devoted  to 
informal  ‘facilitation’  payments.  They  try  to  distinguish  between  different  forms  of 
corruption and facilitation payments. The regulation that legalised informal payments after 
treatment is in line with the Medical Chamber’s advice: as long as informal payments take 
place  after  treatment  and  happen  voluntarily,  it  is  argued  that  they  are  legal  and 
acceptable. 

Due to their lower position in the hierarchy, the younger generation receives fewer informal 
payments. Multiple interviewees also indicated that the younger generation of healthcare 
professionals does not wish to rely on those payments.  

However,  this  is  not  matched  by  top-down  good  practices,  and  according  to  TI,  the 
government is susceptible to the influence of the medical lobby. This was shown when the 
government decided about 1.5 years ago to change the definition of corruption and bribery 
under the criminal code, legitimising after-treatment informal payments. The change was 
a symbolic gesture, as in realty, physicians were not being prosecuted or convicted in any 
case. 

The  Minister  of  State  for  Healthcare  on  the  other  hand  noted  that  two  strategies  are  in 
place  to  address  the  problem  of  informal  payments.  The  first  regards  patient  safety 
projects. Over half of the funds received from the EU today will be spent on patient safety 
issues,  and  the  government  will  develop  quality  indicators  to  assess  patient  safety.  The 
Minister of State believes that when the processes become more transparent and patients 
know what happens to them, the feeling that there is a lack of safety will disappear.  

Healthcare salaries 

The other strategy concerns an increase in the wages of healthcare professionals. In many 
studies  the  main  justification  offered  to  justify  informal  payments  is  that  healthcare 
professionals’ salaries are too low. In an effort to address this, last year the government 
was  able  to  conclude  an  agreement  with  the  trade  unions.  As  a  result,  healthcare 
professionals  (other  than  physicians)  will  see  their  salaries  doubled  over  the  next  four 
years. For physicians a two-year agreement was concluded, in which their salaries increase 
by 500 EUR a month this year, and a further 500 EUR a month next year.85 

If the wage increases are implemented as planned on the 1st of November 2017, this will 
put the salaries of healthcare professionals at around the average of the Visegrad group 
countries.86  This  means  that  wages  can  no  longer  be  used  as  an  argument  to  justify 

85 Please note that, as the financing of GPs is based on capitation they were not included. Their remuneration 
has however increased by 50% over the past 6 years. 
86 A political grouping of Central and Eastern European countries, including the Czech Republic, Hungary, Poland 
and Slovakia. See http://www.visegradgroup.eu/. 

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Updated Study on Corruption in the Healthcare Sector  

informal payments. The Minister of State wonders when citizens will start calling informal 
payments ‘corruption’ instead of ‘gratitude payments’.  

3.4.8.  Challenges and conclusions 

Healthcare-related 

The  main  structural  problem  is  that  there  are  fewer  nurses  and  family  doctors  (general 
practitioners, GPs); on the one hand because people do not have enough money to come 
up with the informal payments required, and on the other because many younger people 
do not want to work in such an environment. Many younger physicians go abroad and, as 
a consequence, the average age of GPs is increasing. Some of these GPs may need the 
informal payments to supplement relatively low salaries, and generally GPs do not see the 
informal payments as being unaffordable. There seems to be a form of acquiescence, as 
there is no general public discussion about informal payments. 

Promoting the role of GPs and avoiding unnecessary use of secondary and tertiary care is 
important. Financial incentives should accompany this, to attract more GPs and enhance 
the  labour supply.  Strengthening the  referral  system through control  and  organisational 
measures, as well as developing more data-driven approaches to healthcare, should limit 
the use of specialist and hospital care. 

These challenges were also reported in the recent publication on Health Care and Long-
term Care Systems & Fiscal Sustainability (2016).  

Corruption-related 

There  are  no  directed  policies  to  tackle  corruption,  and  there  is  a  general  apathy  about 
corruption  among  citizens.  The  government  denies  that  what  is  happening  is  a  form  of 
corruption, and argues that it aims to promote the Hungarian owner-class. 

Hungary  lacks  adequate  whistle-blower  protection.  There  is  legislation  in  place,  as 
prescribed  by  the  UN  convention  against  corruption  and  the  European  Commission. 
However, this is viewed by TI as a ‘box ticking exercise’, which has no real effect in practice.  

In addition, there is no specialised anti-corruption process, nor a specially designated anti-
corruption agency – and indeed, there is no public discussion on whether one should be 
designated. You can go to the Ombudsman or turn to the police to report corruption, but 
according to TI this is insufficient to tackle corruption effectively.  

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3.5.  Poland 

3.5.1.  Overview/summary 
The fact-finding mission to Warsaw, Poland took place from 25 - 27 January 2017. In total, 
six  interviews  with  stakeholders  from  different  categories  (e.g.  regulators,  industry, 
consumer associations, payer and others) were conducted. An overview of the details can 
be found in the Table below.  

Table 3.18 Overview of Interviewees 

Date 

Organisation  

25 – 01  

Infarma Poland  

Ministry of Health  

MedTech; IPDDL and Polmed  

Batory Foundation  

26 -01 

26 -01 

26 -01 

27-01 

27-01 

Polish Consumer Federation  

Consumer association  

National Health Insurance Fund (NFZ) 

Payer  

Stakeholder category 

Industry  

Regulator  

Industry  

Civil society 

3.5.2.  General description of the healthcare system 
Poland  has  a  system  of  mandatory  health  insurance  that  is  complemented  by  financing 
from the state and the territorial self-government budgets. Almost 98% of the population 
is covered by the insurance that ensures access to a wide range of healthcare services. 
Voluntary health insurance can be purchased, but this does not play a big role in the Polish 
health system.  

Within the health system there is a clear separation between financing and provision: the 
National Health Fund (NFZ) is the sole payer in the system and contracts, through its 16 
regional branches, both public and non-public providers. Employees pay health insurance 
contributions that are collected by two intermediary organisations, pooled by the NFZ, and 
then divided among the16 regional branches of the NFZ. The health insurance contributions 
are proportional and the budgetary subsidies progressive, however the high level of out-
of-pocket expenditures (calculated on the basis of monthly salary) is regressive.  

The health system in Poland is highly decentralised: the Ministry of Health is the key policy 
maker  and  regulator.  The  Ministry  of  Health  focusses  mainly  on  policies  and  guidelines, 
and  aims  to  monitor  and  control  the  different  departments  and  healthcare  facilities.  In 
addition  to  the  Ministry  of  Health,  three  levels  of  territorial  administration  and  self-
government  exist  (i.e.  gmina,  powiat,  voivodeship),  each  having  their  own  tasks  and 
responsibilities with regard to healthcare (e.g. prevention and healthcare infrastructure). 
Because of the independence of the territorial self-governments, coordination of activities 
can sometimes prove difficult.  

Perception of corruption in the Polish healthcare system  

Transparency  International87  ranked  Poland  30/168  countries  on  the  Transparency 
International corruption list. The score given to Poland was 62, whereby 0 stands for highly 
corrupt and 100 for very clean. A study published in 2013 showed that the public perceived 
the  healthcare  sector  as  the  second-most  corrupt  sector  in  Poland,  after  politics. 
Furthermore, in Poland 15% of the respondents admitted paying for a bribe in 2014, for 
which nine out of ten where in the healthcare sector.88 

87 https://www.transparency.org/country/POL#.  
88 http://www.economist.com/news/europe/21647087-central-and-eastern-europe-low-paid-doctors-accept-
bribes-and-patients-offer-them-patients-bearing.  

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Healthcare delivery 

In  Poland  most  hospitals  are  public  and  most  primary  and  ambulatory  care  provision  is 
private. The private sector is still  relatively young and only recently developed. Another 
important development is the increase in number of public hospitals.  

A study published in 2013, shows that 65% of all patients use private healthcare facilities. 
91% of pregnant women prefer private healthcare over public healthcare. Private care is 
also used to bypass waiting lists in the public hospitals (please refer to section 3.5.4. for 
more details).  

In  order  to  access  specialist  care  (both  ambulatory  and  inpatient);  patients  require  a 
referral by a primary care physician. People can choose to register with any primary care 
physician that is contracted by the NFZ and are allowed to switch twice every year.  

Primary care is financed using annual capitation whereas specialist ambulatory care uses 
fee-for-service  payments.  For  inpatient  care  a  DRG  like  system  is  used,  regardless  of 
whether it is at a public or private hospital and which services the hospital provides.  

Note that in Poland certain types of patients, such as war veterans and honorary blood and 
organ donors, have a priority status within the waiting list system.  

Table 3.19 Indicators of the healthcare system in Poland 

Indicators of the healthcare system  

Financing of the healthcare system (1) 

Total health expenditure as % of GDP 

Public expenditure as % of total health spending 

2012 

2015 (or 

EU 

nearest year) 

average 

6.2% 

70.0% 

6.3% 

71.6% 

10% 

77.8% 

Private insurance as % of total health spending 

0.8% 

4.0% (2013) 

2.2% 

Private-out-of-pocket as % of total health spending 

24.3% 

23.6% 

(2013) 

13.9% 

Organisation of the healthcare system (2) 

Social insurance or tax-based system? 

Gatekeeping by a general practitioner (GP)? 
How are physicians paid? (e.g. salary, fee-for-service, 
capitation) 

Social 

insurance 

Compulsory 
Salaries, 
Capitation & 
Fee –for-
service 
DOI: 10.1787/data-00349-en, 

(1) 

Sources: 
OECD: 
DOI:10.1787/health_glance-2015-graph156-en, Eurostat healthcare expenditure by financing agent, (2) World 
Bank. 

expenditure 

indicators’ 

‘Health 

OECD 

Table3.20 Corruption in healthcare perceptions in Poland 

Corruption in healthcare perceptions  

Do you think that the giving and taking of bribes, and the abuse of positions of power 

for personal gain, are widespread among people working in the public health sector?  

2011* 

2014** 

EU 
average** 

(% of respondents agree - Eurobarometer) 

48% 

53% 

33% 

Sources: Special Eurobarometer 374, table QC4 (fieldwork September 2011); Special Eurobarometer 397, 2014 
(fieldwork February - March 2013), Annex IV. 

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Table 3.21 Corruption Perception Index (CPI), Poland 

Corruption Perception Indez 

Score 

Rank 

2016 

62* 

29*** 

Source: www.transparency.org; * CPI score is based on a scale ranging from 0 to 100, a score of 0 indicates the 
country is perceived as very corrupt and a score of 100 indicates a country is perceived as very clean; ** the 
2012 CPI ranked 174 countries, where a lower rank indicates a cleaner country; *** the 2016 CPI ranked 176 
countries, where a lower rank indicates a cleaner country.  

3.5.3.  Risks and obstacles 
The main obstacles and risks for the Polish healthcare system are:  

  Different perceptions of what corruption is; 
  Low public healthcare expenditure;  
  Long waiting lists for specialist public healthcare; 
  Lack of knowledge on medical equipment at small hospitals. 

Each of these risks is described in more detail below. 

Different perceptions of corruption 

One of the main findings of the fact finding mission was the different understanding among 
stakeholders regarding corruption. The general public in Poland seems to perceive under-
the-table  payments  as  a  form  of  corruption,  while  using  your  contacts,  e.g.  family  and 
friends, to obtain a higher place on a waiting list, is seen as a normal practice. People do 
not recognise the unethical aspects of such behaviour and the fact that other people may 
have reduced access to healthcare services is not seen as an outcome of such behaviour. 
One of the explanations might be that many Poles have both a public and private insurance. 
In order to bypass a waiting list, a patient first goes to the private clinic where a referral 
to the public hospital can be obtained. Many of the treatments are only available in public 
hospitals. However, by obtaining a referral from a private clinic to a public hospital, one 
gets to be placed higher on the waiting list.  

All  in  all,  one  can  conclude  that  informal  payments  are  perceived  as  corrupt  behaviour, 
while unethical behaviour regarding privileged access is apparent standard behaviour.  

Low public healthcare expenditure  

The  public  healthcare  expenditure  in  Poland  is  5.4%  of  GDP  compared  to  10%  on  EU 
average. This means that in Poland around 700 US dollars per capita is spent on healthcare. 
Compared to similar countries, the Polish expenditure is rather low. For instance, the per 
capita  spend  in  the  Czech  Republic  and  Slovenia  equals  2,000  US  dollars.  For  other  EU 
countries the per capita spending is much higher. For example, spend on healthcare in the 
Netherlands and Germany amounts to 7,000 US dollar per capita. Low public healthcare 
expenditure  may  lead  to  physicians  looking  for  jobs  –  with  better  working  conditions  – 
abroad, which in turn results in long(er) waiting lists.  

The Polish government aims to increase the spending on public healthcare to 6% before 
2020. In addition, several healthcare reforms have been proposed. Currently, the system 
is  based  on  an  income  related  system.  A  percentage  is  deducted  from  the  employee’s 
salary and directly transferred to NFZ, the sole payer in the Polish system. The government 
proposes to transform this system into a tax-based system, where people need to transfer 
the  contributions  themselves.  Although  the  contribution  will  become  more  visible, 
stakeholders  doubt  whether  the  budget  will  be  actually  increased  as,  based  on  some 
calculations, the amount collected seems to remain equal.  

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Long waiting lists in order to receive specialist public healthcare  

Long  waiting  lists  pose  a  severe  risk  for  the  Polish  healthcare  system.  Due  to  a  lack  of 
physicians,  waiting  lists  are  long.  In  addition,  most  Poles  are  insured  twice;  they  are 
publicly  insured  and,  when  they  are  employed,  they  are  also  privately  insured.  When 
visiting a physician, the patient can either opt for public or private healthcare. However, 
when more specialised care is required, the patient can only go to a public hospital as most 
private clinics only offer basic care. In order to get easier access to a public hospital, the 
patient visits the physician in the private clinic and obtains a referral for the public hospital.  

Although several attempts have been made to make waiting lists more transparent, the 
initiatives have not been successful so far. Patients can only see how long the lists are, but 
remain unaware of their own position and the positions of others. Some stakeholders also 
indicated  that  lists  are  not  frequently  updated  and  therefore  contain  much  outdated 
information.  

Lack of knowledge on medical equipment at small hospitals 

Public  procurement  is  organised  at  a  decentralised  level  and  each  hospital  or  medical 
facility  is  responsible  for  its  own  procurement.  However,  most  hospitals  do  not  have 
specialised  personnel  that  could  support  the  procurement  process  and  therefore  the 
physicians themselves have to engage in a tender process. The tender specifications are 
written by the physicians who have to base such specifications on their own knowledge of 
medical equipment. Where physicians are not able to write down the required level of detail 
they  sometimes  request  the  help  of  industry  players.  It  can  happen  that  the  medical 
company drafts the technical specifications in such detail that only one specific company 
can win the tender.  

3.5.4.  Types of healthcare corruption 
In Poland different forms of corruption exist. The main ones identified are: 

Informal payments; 

 
  Privileged access; 
  Double practices; 
  Procurement of medical devices; 
 
 

Improper marketing; 
Improper influencing of patients. 

Informal payments  

Informal payments used to be very common in Poland. However, during the last couple of 
years  it  has  become  less  common  to  pay  the  physician  before  treatment  is  received. 
Several reasons for this decline in under-the-table-payments have been given. First and 
foremost,  the  salaries  of  medical  personnel  have  increased  substantially  and  most 
physicians, aside from those who have just finished their studies, earn a decent income. 
The  higher  salaries  have  taken  away  the  incentive  to  ask  for  additional  favours  from 
patients. Second, more physicians have opted to work both in a private and public hospital, 
which  is  legally  allowed  in  Poland.  By  combining  the  two  jobs,  the  physicians  have 
increased their salaries in a legal manner. Third, the anti-corruption bureau has been active 
in  prosecuting  physicians  who  accepted  bribes.  These  cases  also  received  much  media 
coverage and were publicly debated. As a result, physicians also became more scared of 
taking  bribes  and  patients  became  aware  of  the  fact  that  they  do  not  have  to  pay  a 
physician.  

Although informal payments to get access to physician have decreased, other payments 
are still made. Stakeholders explained that each patient is insured for a minimum level of 
care. To receive this care no additional payments have to be made, as it is insured either 
by the public or private insurance. However, if a patient requires some additional service, 
payment may be needed, unless the physician is of the opinion that the care needs to be 

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given. For example, giving birth in a natural way is insured for all women. However, where 
a woman would prefer a caesarean, but there is no medical need to perform one, she is 
required to pay the additional costs herself and in such cases, pays the physician directly 
instead of paying the insurance company.89  

Privileged access 

Waiting lists may pose a risk for irregularities/corruption. The previous government made 
progress in regulating waiting lists and creating much more transparency. The main aim is 
to introduce one central waiting list which should ensure more or less the same level of 
access to certain medical treatment in each region. However, in some regions patients can 
still  face  problems  with  waiting  lists;  particularly  in  terms  of  specialised  treatments  the 
waiting list might not provide insights into the real waiting time.  

In order to be ranked higher on the waiting list it is common to first visit a physician via a 
private appointment before being admitted to a public one where the same physician is 
also working. This current system enables privileged access and creates a ‘grey area’ of 
corruption. The current system works as follows: 
1.  Patients gather information about where they want to receive treatment, i.e. in which 

public hospital;  

2.  They search for the best public specialist working in that field;  
3.  They search for the private clinic this physician works in;  
4.  Visit the clinic and make an appointment with the preferred specialist; 
5.  Mention their interest being treated at the public hospital, and the physician gives them 

the contact details of the secretary in the public hospital; 

6.  The patients get privileged access to the public healthcare facilities. 

Double practices 

Closely linked to the above mentioned form of privileged access, is the problem of double 
practices.  Many  physicians  work  both  in  public  and  private  hospitals.  As  most  private 
hospitals only offer basic care, patients need to be referred to public hospitals to receive 
more specialised care. In the public hospital, they are treated by the same physicians. This 
leads to the risk of double practices.  

Public procurement of medical devices 

As already mentioned above this type of corruption is quite common in Poland, especially 
with regard to high tech medical equipment. Due to the lack of knowledge on the side of 
the  procuring  body  (i.e.  the  hospital  itself)  and  the  wrong  incentives  of  the  healthcare 
procurement system (i.e. no system of checks and balances at hospital level), corruption 
occurs frequently. Physicians ask medical service providers to assist them in drafting the 
tender specifications. Such specifications become so detailed that only one company can 
successfully  bid.  Medical  service  providers  also  use  other  strategies  to  influence  the 
procurement processes of hospitals.  

Improper marketing  

Improper  marketing  was  a  recurrent  theme  during  the  interviews.  Many  stakeholders 
indicated actions taken to reduce improper marketing. All initiatives taken can be qualified 
as self-regulation and focus on what can and what cannot be reimbursed by the industry. 
Such codes of conduct are adopted both at government level, e.g. within the Ministry of 
Health and NFZ, and at industry level. For example, a code of good practices exists for the 

89 http://www.economist.com/news/europe/21647087-central-and-eastern-europe-low-paid-doctors-accept-
bribes-and-patients-offer-them-patients-bearing.  

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pharmaceutical industry and the medical equipment providers have adopted the MedTech 
Europe code of conduct. Despite having much self-regulation in place, improper marketing 
still takes place, as not all industry is party to the codes of conduct.  

Improper influencing of patients 

Besides offering physicians extras when prescribing certain medication or advising on small 
medical equipment, the industry also targets patients. Although it does not directly relate 
to  corruption,  several  examples  were  mentioned  during  the  fact  finding  mission,  were 
patients were treated improperly. 

An example mentioned related to patients with a relatively rare illness. This group could 
potentially become victims of improper marketing, as their medication is often expensive 
and prices might have been set too high. The patients are made aware of new medications 
during  conferences  and  meetings  of  support  groups  for  patients  with  rare  diseases. 
However,  often  it  is  unclear  if  the  medication  promoted  by  the  industry  will  be  useful. 
Nevertheless, patients are willing to pay high prices for such medications (as they are often 
desperate).  

Another  example  relates  to  case  3  (see  next  section)  which  is  described  in  more  detail 
below. In this case patients are called by one pharmaceutical company that tries to sell 
patients expensive medication, although it is not clear whether the patient needs this type 
of medication.  

3.5.5.  Recent cases 

Most recent types of cases  

During  the  interviews  held,  some  general  types  of  cases  occurring  in  Poland  were 
mentioned. Below the main types are presented: 
1.  Physicians deliver fictional services and get reimbursement for these treatments without 

actual delivery of the services;  

2.  Patients receives treatment in the private sector, although it is reimbursed by the public 

sector; 

3.  Prescribed medicines are not delivered to patients;  
4.  Medicines  are  procured  in  Poland  for  a  relative  low  price  and  sold  to,  for  example, 

Germany (parallel export). 

In other cases, patients are asked to pay for medication that is also covered by the public 
health fund (i.e. NFZ). In such cases, the patient pays twice, without actually realising this 
is the case. It also happens that potential customers are asked to fulfil other requirements, 
all of them unnecessary (and sometimes illegal).  

Cases 

During  the  fact-finding  mission  different  stakeholders  mentioned  the  following  recent 
cases. 

Case 1 (2017) – Treating fake patients 
On the 20th of January 2017, there was a scandal in the media; it was a story about a physician who lives 
near  the  German  Border  and  worked  as  a  GP.  Besides  acting  as  a  GP,  the  accused  also  worked, 
simultaneously,  at  the  branch  office  of  NFZ  (the  national  insurer),  where  she  got  access  to  the  patients’ 
database. Based on this ‘double practice’ she created her own database of more than 3,000 patients. She 
claimed that all these 3,000 came for regular consults and received treatment. With the help of the integrated 
patient system (in which all treatment data for each patient are included) it was possible to establish that 
half of the patients had never consulted this GP or received any treatment from her.  

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Case 2 (2017) – Bribery in the form of medical devices 
In  January  2017,  an  investigation  was  launched  regarding  bribery  in  the  form  of  medical  devices.  The 
academic hospital in Krakow was accused of receiving expensive medical equipment (worth PLN 600,000) 
from medical companies to use in the hospital. However, the equipment was not used in the hospital, but 
was  transferred  to  a  private  clinic.  Only  patients  in  the  private  clinic  could  benefit  of  this  equipment.  The 
police  searched  16  medical  facilities,  including  the  academic  hospital,  and  several  private  companies.  No 
people have been arrested yet, as the prosecution has not yet been able to establish who benefits from this 
deal. 90 

Case 3 (2016) – Offering of medical packages by phone 
A recent case, brought to the attention of the Polish Consumer Federation, relates to direct sales of medication 
packages to elderly people. One company approaches elderly people by phone and convinces them that they 
need a certain type of medication package. However, it is unclear whether that specific type of medication is 
effective and the scope of the treatment offered is unclear as well. The explanations offered to the potential 
customer are very vague and are often not understand by the elderly people. In some cases, the information 
is also misleading. 

Often this medication is very expensive (ranging from EUR 1,000 to EUR 4,000) and the potential customer 
is not able to pay for the medication. In order to ensure that the potential customer can afford the medication, 
the company offers additional services, e.g. a bank loan or another form of additional financing. By offering 
this  additional  product,  the  potential  customer  becomes  a  consumer  and  the  Polish  Consumer  Federation 
could assist them in filing a complaint.  

Case 4 (2016) – Bribery for sick leave statements 
The Silesian police gathered evidence regarding a 66-year old physician that falsely provided patients with 
sick leave letters in return for bribes in the period 2010 - 2014. The physician had three accomplices who 
were  also  arrested  by  the  police.  Overall,  the  police  collected  evidence  for  169  charges  of  which  152  are 
currently being heard by a judge. The case of the physician is currently pending in court and the verdict could 
be up to 10 years imprisonment. 91  

Case 5 (2016) – Bribery and false documentation 
This case concerns bribes of six suspects and a total of 60 charges. Detailed investigations showed that a 
53-year-old physician accepted bribes in exchange for the so-called sick leave statements, while a 49-year 
old  physician  changed  personal  details  on  medication  prescriptions  and  therefore  falsely  claimed 
reimbursement for the medication. In addition to these to physicians, four other people were arrested for 
actively paying bribes. The 53-year-old physician faces up to 10 years imprisonment. In addition, the four 
other suspects can face prison sentences of maximum 10 years. In contrast, the 49-year-old medic could be 
sentenced to 3 months to 5 years for falsifying the documents. 92  

Case 6 (2016) - Bribery for sick leave statements 
The police collected evidence regarding a 62-year old physician who issued sick leave letters in return for 
money, alcohol, and cigarettes. The criminal dealings lasted for almost 10 years. The physician confessed to 
the accusations and will stand trial for 40 charges. The case is pending in court. 93 

Case 7 (2016) – Requesting bribes for extended hospital stays 
A 44-year old physician told his patients that they could no longer remain on the ward and would need to go 
home, although the patients still needed medical assistance that could only be given to them in the hospital. 
In  return  for  a  payment,  the  patients  could  stay  longer  and  receive  the  care  required.  Awaiting  the  court 
case, the physician is temporarily suspended and has had to pay bail of PLN 50,000. He faces up to 10 years 
in prison.’94 

Case 8 (2014) – Bribery in prescription of medicines 
‘A  foreign  drug  company  and  eleven  Polish  medical  specialist  have  been  charged  with  corruption.  These 
medical  specialists  had  signed  contracts  with  pharmaceutical  company  and  received  payments  when 
prescribing their specific drug to their patients.95 

90 http://www.dziennikpolski24.pl/aktualnosci/a/afera-ze-sprzetem-do-poszerzania-tetnic,11672662.  
91 http://www.antykorupcja.gov.pl/ak/aktualnosci/12177,169-zarzutow-korupcyjnych-dla-lekarki-posrednikow-
i-pacjenta.html.  
92 http://www.antykorupcja.gov.pl/ak/aktualnosci/12175,60-zarzutow-za-tzw-lewe-zwolnienia-recepty-i-
lapowki.html. 
93 http://www.antykorupcja.gov.pl/ak/aktualnosci/12110,Korupcyjne-zarzuty-dla-lekarza.html. 
94 http://www.antykorupcja.gov.pl/ak/aktualnosci/12146,Slascy-policjanci-zwalczajacy-korupcje-zatrzymali-
nieuczciwego-lekarza.html. 
95 http://www.bbc.com/news/business-26970873. 

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3.5.6.  Recent policy developments and best practices  
Since the 2013 Ecorys study on corruption in the healthcare sector, several policy initiatives 
have  been  taken  by  the  Polish  government  and  other  relevant  stakeholders.  The  main 
initiatives are: 

Initiatives taken within the government to prevent corruption; 

  Adoption of the anti-corruption plan; 
 
  Patient related initiatives; 
  Self-regulation in the industry. 

Anti-corruption plan 2014 - 2019 

During the last couple of years, some recent policy developments were made. The most 
important  development  is  the  adoption  of  the  anti-corruption  plan  by  the  national 
government. The anti-corruption plan (2014 – 2019) applies to the entire government. The 
plan does not specifically focus on the healthcare system, but also covers other sectors. 
The  relevant  article  for  the  healthcare  sector  is  article  7  of  the  strategy,  which  deals 
exclusively with the actions envisaged for preventing corruption in the healthcare sector. 

Article  7  identifies  the  following  areas  that  need  specific  tools  and  measures  to  combat 
corruption:  

  Reimbursement of medication; 
  Public procurement; medication and medical technology; 
  The physician-patient relationship; 
  The  relation  between  the  physician  and  the  pharmaceutical  industry  and  vice 

versa; 

  The relation between the insurers and the physicians and vice versa; 
  The contracting of the national health insurance fund.  

Based on the program, both the Ministry of Health and NFZ (the national health fund) have 
taken several actions. 

As part of this program, the National Health Fund established an internal working group, 
which from early 2016 onwards, performed an extensive audit of all internal documents 
and  procedures,  especially  the  ones  in  relation  to  business  trips  and  contact  with 
contractors.  By  the  end  of  2016,  the  final  report  of  the  working  group  was  send  to  the 
Ministry of Health.  

An  example  of  a  procedure  reviewed  was the procedure  regarding  business  trips, which 
are  heavily  regulated.  NFZ  employees  are  not  allowed  to  take  reimbursements  from 
industry. They are only entitled to a DSA and travel costs. Even if they deliver a speech or 
a presentation at a congress, they are not allowed to get paid by the industry. In addition, 
entrance fees to conferences cannot be sponsored by the industry. 

Initiatives to prevent corruption taken within the government 

At  a  governmental  level,  several  initiatives  have  been  taken  to  prevent  and  combat 
corruption. The main initiatives are presented below. 

The  Ministry  of  Health  has  established  a  reimbursement  commission,  which  assesses 
whether  or  not  certain  payments  are  in  line  with  the  Ministry’s  guidelines.  The 
reimbursement committee needs to make detailed minutes of all meetings held, and these 
minutes will be publicly available. A one-on-one meeting is prohibited, as it is qualified as 
a meeting with a high risk for corruption.  

Another  initiative  is  the  so-called  anti-corruption  shield  that  monitors  all  actions  of  staff 
members,  including  their  spouses,  regarding  agreements  on  reimbursements  and  other 
promotional activities. The shield aims to protect the employees and tries to ensure that 
they are not involved in any unwanted practice.  

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Furthermore, new staff is not allowed to have contact with the industry and vice versa. If 
a person wishes to switch from the private sector to the Ministry of Health or vice versa, a 
waiting period has to be followed. During this period, the person is not allowed to work in 
either of the two sectors. 

National consultants who give advice to the Ministry of Health about policies need to sign 
statements  in  which  they  claim  that  they  do  not  work  for  private  companies  as  well. 
Moreover, staff members and the national consultants need to give inside in their salaries.  

The national insurance fund has appointed two employees fulltime at its headquarters to 
perform internal monitoring and to ensure that nothing irregular happens. At each of the 
16 branch organisations, one employee per branch is appointed. The branches control and 
check each other in order to ensure that all procedures are followed. In addition to that, 
there  are  subject-based  controls  of  different  units.  Each  year,  3-4  branch  offices  are 
controlled  /  checked  in  respective  departments  /  units,  for  example  on  accounting, 
financing, Human Resources and international financial settlement.  

Moreover,  the  financial  budget  plans  are  controlled  by  the  finance  departments  of  the 
Ministry of Health and the Ministry of Finance. The two different stakeholders check the 
plan. Parliament, more specifically the Commission on Health and the Commission on Public 
Finance also control the budget.  

Patient related initiatives 

A  recent  development  made  by  the  national  insurance  fund  enables  patients  to  see  the 
general waiting lists (i.e. number of people on it). In the near future patients will also see 
their  own  position  on  the  list  (they  will  have  a  number  with  their  name  attached  to  it). 
During  the  interviews,  it  became  clear  that  there  are  different  opinions  about  the 
usefulness of these waiting lists. A stakeholder mentioned that the waiting lists that are 
available  on  internet  are  not  up-to-date.  In  addition,  there  is  no  external  pressure  to 
update these waiting lists. This is the reason why patients call friends and family to gather 
information about waiting times and to exchange experiences on healthcare received. 

Another  development  of  the  national  insurance  fund  is  the  central  patient  information 
system. Each patient can check his/her file online and receives in-depth information on the 
care  received.  Based  on  this  information,  the  patient  can  file  a  complaint  when  he/she 
discovers that care not actually received, has been included on the form. 

Self-regulation in the industry 

Within  the  Polish  industry,  in  terms  of  both  pharmaceutical  companies  and  medical 
equipment providers, several self-regulating codes have been adopted. In addition to these 
codes, some tools and training programs have been developed, all aiming to make medical 
professionals  and  industry  players  aware  of  the  right  business  ethics  that  needs  to  be 
followed in order to combat corruption. 

The pharmaceutical industry has taken several measures that aim to prevent and control 
corruption: 

  Ethical code – Code of good practices + supporting web-based tool; 
  Transparency code; 
 

Internal disciplinary court;  

The  code  of  good  practices,  implemented  in  2008,  provides  guidance  on  ’the  promotion 
and advertising of medicinal products, the organisation of symposia, congresses and other 
scientific meetings, the administration of research, and collaboration with representatives 

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of  medical  professions  and  patients'  organisations.’96  The  code  is  based  on  the  code 
adopted by EFPIA, the EU association for pharmaceutical companies.  

Organisers of conferences and other events need to ensure that their conference or event 
is in line with the standards laid down in the code of good practices. Once the event is in 
line,  the  organiser  can  receive  a  certificate  that  serves  as  proof  of  compliance  with  the 
ethical standards set. Members of the code are able to attend the event, without the risk 
of attending an event that is not in line with the ethical standards.  

Closely linked to the code of good practices, the pharmaceutical association has established 
a working group, which is developing a web-based tool, which will automate the process 
of certifying events. This tool is country / sector specific and is currently in testing phase. 
The official  launch is planned for 2018. An event will fall  into one of three categories of 
certificates (green, amber and red) depending on its compliance with Infarma codes. Green 
certificates are a sign for member companies that the event is safe to attend and thus in 
line  with  the  ethical  standards.  The  red  certificate  can  be  corrected  once  the  venue, 
program or other is modified in line with codes and standards. 

The  transparency  code  of  EFPIA  governs  disclosures  regarding  cooperation  between 
healthcare professionals and healthcare organisations. This code was implemented in 2015 
in  Poland.  97  There  is,  moreover,  a  transparency  register  in  place.  Currently  22%  of 
physicians  are  registered,  providing  insights  into  their  salaries  and  financial  benefits 
received, for the pharmaceutical industry. 

The last initiative of the pharmaceutical industry is the internal disciplinary court. Whenever 
members of Infarma violate the above-mentioned codes, member companies can resort to 
the internal disciplinary court. The court can exercise its power to educate and discipline 
member companies. 

In  addition,  the  medical  equipment  suppliers  also  have  codes  of  ethics.  Several 
associations, e.g. one for distributors of medical devices and one for laboratory personnel, 
represent  these  companies.  These  associations  have  adopted  the  Code  of  Ethics  of 
MedTech  Europe  and  as  a  result,  the  same  rules  apply  to  the  associations  and  their 
members.  The  code  has  been  translated  in  Polish  and  is  fully  in  line  with  the  MedTech 
Code. 

The  medical  supplier  associations  also  have  introduced  training  programs  in  which  they 
inform their members about the new code and its implications. The main aims and benefits 
of the training are:  

  To spark an open dialogue between suppliers and healthcare professionals; 
  To  raise  awareness  and  esteem  of  certain  medical  professions  through 
continuous  education  of  health  care  practitioners  in  the  fields  of  law,  ethical 
standards and best practices; 

  Strengthen  self-regulation  of  the  IVD  sector  and  standardisation  of  best 

practices by leading companies operating in the Polish market. 

3.5.7.  Challenges and conclusions 
The  main  challenge  in  Poland  is  the  underfunding  of  the  healthcare  system.  As  indicate 
before, the total public spending on the sector is 5.4% of the GPD, while the EU average 
is 10%. Although the government aims to increase the spending to 6% and some reforms 
are proposed, these actions do not seem to tackle the problem of underfunding. One of 
the most important changes will be the shift from a social insurance system to a tax based 

96 https://en.infarma.pl/ethics/code-of-good-practices/. 
97 http://transparency.efpia.eu/countries/download/20/document_3/transparency-code_edit_3_140814-
9effective-27-09-2014).pdf. 

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system. However, preliminary calculations indicate that the total amount collected will not 
change as a result of this change. 

Another large problem in the Polish healthcare system is the long waiting lists, which are 
caused by a lack of physicians. There are not enough medical professionals available in the 
Polish system, which leads to long waiting lists.  

Closely related to the problem of long waiting lists, is the lack of transparency of the waiting 
lists. Patients are not able to obtain any insight into their position on the lists, let alone be 
able to compare their position with that of other patients. In addition, the waiting lists are 
not frequently updated and often present old information.  

Together,  these  problems  regarding  waiting  lists,  the  lack  of  physicians,  and  the  non-
transparency of the lists themselves, create the potential for corruption, as many Polish 
people use the combination of private and public health insurance to quickly bypass the 
long waiting lists. As was indicated several times in the report, bypassing the waiting lists 
is common in Poland. As was also indicated, many Poles do not consider this as a form of 
corruption, but as standard practice. 

The  Polish  government  has  adopted  many  procedures  and  guidance  regarding  improper 
marketing. The guidance adopted can be qualified as self-regulation and is often strongly 
internally  focused,  so  the  relation  between  government  staff  and  the  industry  is  clear. 
However,  the  Polish  government has  adopted  less  guidance  or  initiatives  on  combatting 
other types of corruption. There is an anti-corruption plan (2014 – 2019), but the actions 
for the healthcare sector laid down in this plan are rather generic and it is not yet clear 
how they will be fully implemented.  

In addition, the industry itself has adopted self-regulation, e.g. the Code of good practices 
and the Transparency Code adopted by the pharmaceutical industry and the Code of Ethics 
for  the  Medical  equipment  providers.  Although  these  Codes  form  a  good  basis  for 
combatting improper marketing, it should be noted that several companies active in Poland 
are  not  bound  by  these  Codes,  as  they  are  not  members  of  the  associations  that  have 
adopted the Codes. Therefore, the Codes only apply to part of the industry active in Poland.  

Corruption in the public procurement systems is still common in Poland; however, there is 
not much information about the prevalence of this type of corruption. The main risks for 
this type of corruption are the lack of knowledge on the side of the hospitals responsible 
for the procurement, and gaps in the legislation.  

As  mentioned  in  the  recent  publication  on  Health  Care  and  Long-term  Care  Systems  & 
Fiscal Sustainability (2016), the Ministry of Health is particularly vulnerable to lobbying, 
informal  pressures  and  corruption  proposals  by  external  stakeholders,  particularly  the 
pharmaceutical  industry.  Steps  have  been  taken  in  collaboration  with  the  EHFCN  to 
improve transparency and decrease risks. 

It seems that petty corruption in healthcare is becoming less common in Poland, as the 
informal payments are decreasing. The decrease in informal payments can be explained 
by the stronger likelihood that corrupt physicians will be caught and prosecuted. Another 
explanation given for the decrease in informal payments is the rise in salaries, which also 
make it less essential for physicians to ask for additional payments. 

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3.6.  Romania 

3.6.1.  Overview 
The  fact-finding  mission  to  Bucharest,  Romania,  took  place  between  6  and  8  December 
2016. During this mission, four face-to-face interviews were held. In addition to the mission 
to  Romania,  phone  interviews  were  conducted  with  the  World  Bank,  a  civil  society 
representative,  and  a  representative  of  the  Ministry  of  Justice.  An  overview  of  the 
interviews conducted is presented below. 

Table 3.22 Overview of interviews in Romania 

Date 

Organisation  

6 December 2016 

Centre for Legal Resources 

Stakeholder 

category 

Civil society 

7 December 2016 

DNA (anti-corruption Bureau) 

Public Prosecution 

7 December 2016 

Association for consumers' protection – APC 

Patients 

7 December 2016 

Dutch Embassy 

13 December 2016 

World Bank 

23 May 2017 

25 May 2017 

- 

Ministry of Justice 

Other 

Other 

Civil Society 

Regulator 

3.6.2.  General description of the healthcare system 
The  Romanian  healthcare  system  is  a  social  healthcare  system  that  provides  a 
comprehensive  healthcare  benefits  package  to  85%  of  the  population.98  As  the  state 
guarantees  the  right  to  health  for  every  Romanian  citizen  (according  to  article  34  the 
Romanian  Constitution),  the  remaining  population  has  access  to  a  minimum  benefits 
package (for example emergency services).99  

The Romanian healthcare system is highly centralised, despite efforts to decentralise some 
of the regulatory functions.100 The Ministry of Public Health (MoH), is the central authority 
in  developing  healthcare  policies,  the  provision  of  inspections  and  control,  and  the 
administration  of  national  health  programmes.101  42  districts  (judet),  including  the 
municipality of Bucharest, are responsible for ensuring healthcare provision at local level. 
District public health authorities (DPHAs) represent the MoH at local level.  

In 1998 Romania introduced a national fund for social health insurance, the National Health 
Insurance Fund (NHIF), which is managed by the National Health Insurance House (NHIH). 
NHIH enters into contracts with healthcare providers, for healthcare procurement and the 
reimbursement  of  medical  services.  NHIH  is  represented  by  42  district  National  Health 
Insurance Houses (DNHIHs), which are responsible for contracting services from public and 
private healthcare providers and the reimbursement of medical services. The services to 

98 European Observatory on health Systems and Policies, Romania Health system review, Health Systems in 
Transition, Vol.18 N0.4 2016. 
99 There are two types of medical services: the basic medical services provided to the insured individuals (art. 
221, 1, c of the Law no. 95/2006 on the healthcare reform) and the minimum package of medical services that 
applies to all persons in Romania irrespective of the insurance status. These second type of services that are 
secured unconditionally are emergency medical services, epidemic disease, monitoring pregnancy and lactation, 
family planning services, community health care prevention (art. 221, 1, d of the Law no. 95/2006 on the 
healthcare reform). In order to be insured you have to pay the contribution to the national health funds. 
Payment to the fund is mandatory (article 219, 3, e of the Law 95/2006) and it retained and paid by the 
employer or employment service (article 228, 1) for all employees and social security beneficiaries (article 222, 
1).  Automatically insured without having to pay are pensioners, children, and youngsters during education 
years, persons with disability, pregnant women, and patients with chronical illness etc (article 224). There are 
people that do not have any legal income, do not have social security benefits and are not among those 
automatically insured (ex. people that work without legal forms). They are uninsured, but they may become 
insured if they pay a monthly contribution at the level of contribution for minimum wage (article 224, 4). 
100 European Observatory. 
101 Law no. 95/2006 on healthcare reform.  

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be contracted are stipulated in an annual Framework Contract that is agreed upon between 
the NHIF, the Ministry of Public Health and the College of Physicians. 

Traditionally, each ministry in Romania has its own medical facilities and apparatus (service 
providers). Until 2013, the Ministry of Transport had its own Insurance House that financed 
the service providers of the Ministry. In 2013 the Transport Insurance House was closed 
and the duties, service providers and the persons insured were taken over by the Ministry 
of  Health  and  NHIH  (Emergency  Ordinance  no.  8/20013).  As  such  it  still  functions  the 
Health  Insurance  House  for  Defence,  Police,  National  Security  and  Justice  (OPSNAJ). 
OPSNAJ was put by law under the supervision of NHIH (article 276 of the Law no 95/2006). 
In  fact,  OPSNAJ  functions  like  a Matryoshka  doll  –  a  little  House  within  a  bigger  House. 
OPSNAJ has its own insured persons, and finances the medical services provided by the 
service  providers  established  under  these  ministries.  Nevertheless,  there  is  only  one 
insurance fund to which all contribute, although the fund is split afterward between NHIH 
and OPSNAJ.  

MoH and NHIF are central in the provision of healthcare in Romania, including the control 
of corruption and abuse, in particular in direct relation to corruption in public procurement 
in hospitals and, for example, insurance fraud.102 

Romania spends around 6% of GDP on healthcare, substantially below the EU average of 
10%  (Table  3.23).  About  80%  is  publicly  funded,  which  is  slightly  more  than  the  EU 
average. Most public funding comes from the direct social insurance contributions to the 
National Health Insurance Fund (NHIF)103 plus a small percentage of taxes allocated to the 
Ministry of Public Health. Out of pocket payments are the second largest revenue source 
(about  19%),  which  appear  as  co-payments  on  covered  services,  direct  payments  to 
private providers and payments for uncovered services. In addition informal payments are 
an important source of financing. However, it is not known what the size of this is relative 
to official healthcare payments.  

Healthcare delivery in Romania is based on a gatekeeping system, which assigns a primary 
role  to  the  general  practitioner  in  the  provision  of  healthcare  access.  Patients  need  a 
referral  from  their  general  practitioner  to  be  eligible  for  reimbursed  hospital  care.  The 
majority  of  institutions  providing  secondary  and  tertiary  care  are  publicly  owned  and 
regulated. The current legislation assures free choice of provider for the patient, increasing 
patient participation in decision-making, patient safety and compensation measures. 

General  practitioners  are  paid  by  a  mixed  system  of  fee-for-services  and  per  capita 
payments. Hospital services are compensated by predefined payments, whose calculation 
methods differ by service. Hospital payments for inpatient services are calculated per case 
based on a DRG system. Costs for outpatient services are reimbursed by fee for service. 

Although  the  right  to  healthcare  for  every  Romania  citizen  is  secured  in  the  Romanian 
Constitution,  there  are  widely  noticed  inequalities  in  the  access  to  healthcare  (among 
social-economic  groups  as  well  as  geographical  differences).104  In  addition  quality  of 
healthcare  is  mixed,  while  the  monitoring  of  quality  also  needs  to  be  improved.105 
Inequality in access to healthcare and differences in quality of the services provided are 
core issue of concern from the perspective of the fight against corruption in the relations 
between patients and healthcare providers. 

102 Radu Nicolae, Healthcare corruption – patterns and vulnerabilities in Romania, in: Narrative on Organised 
Crime in Europe. Criminals, Corrupters & Policy. Petrus C. van Duyne, Miroslav Scheinost, Georgios A. 
Antonopoulos, Jackie Harvey, Klaus von Lampe (eds.), Wolf Legal Publishers 2016 Nijmegen. 
103 Collected by the Fiscal Administration National Agency of the Ministry of Finance and allocated to the NHIF 
and subsequently distributed amongst the DHIFs, based on a risk-adjusted capitation system. The contributions 
of the self-employed are directly collected by the DHIFs. 
104 European Observatory. 
105 European Observatory. 

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Table3.23 Indicators of the healthcare system in Romania 

Indicators of the healthcare system, 2015 (or nearest year) 
Financing of the healthcare system (1) 

2012 

5.48% 
80.27% 

0.2% 

19.5% 

2015 (or nearest 
year) 
5.57% (2014) 
80.4% (2014) 

EU 
average 
10% 
77.8% 

1.1% (2014) 

2.2% 

18.9% (2014) 

13.9% 

Total health expenditure as % of GDP  
Public expenditure as % of total health 
spending  
Private insurance as % of total health 
spending  
Private-out-of-pocket as % of total health 
spending  
Organisation of the healthcare system (2) 
Social insurance or tax-based system? 

Social 
insurance 
(mandatory) 
Capitation/FFS 

Gatekeeping by a general practitioner (GP)? 
How  are  physicians  paid?  (e.g.  salary,  fee-
for-service, capitation) 
Patient  organisation  involvement  (3=good, 
2=intermediary, 1=not-so-good) 
Accessibility (3=good, 2=intermediary, 1=not-so-good) (3) 
Family doctor same day access 
Major surgery < 90 days 
Cancer therapy < 21 days 
CT scan < 7 days 

2 
2 
2 
1 

3 

Sources:  (1)  WHO  Health  expenditure  ratio,  per  country,  1995-2014,  Eurostat  healthcare  expenditure  by 
financing agent (2) Joint Report on Health systems (2016), HEIDI WIKI and Euro Health Consumer Index 2012, 
(3) Euro Health Consumer Index 2012. 

Table 3.34 Corruption in healthcare perceptions in Romania 

Corruption in healthcare perceptions  
Do you think that the giving and taking of bribes, and the abuse of positions of power 
for personal gain, are widespread among people working in the public health sector?  

(% of respondents agree - Eurobarometer) 

61% 

67% 

2011* 

2014** 

EU 
average** 
33% 

Sources:  *  Special  Eurobarometer  374,  table  QB7  (2014),  **  Special  Eurobarometer  397,  2014  (fieldwork 
February - March 2013), Annex IV; own research (Feb - March 2013).  

Table 3.25 Corruption Perception Index (CPI), Romania 

Corruption Perception Index 

Score 
Rank 

2016 
48* 
57*** 

Source: www.transparency.org; * CPI score is based on a scale ranging from 0 to 100, a score of 0 indicates the 
country is perceived as very corrupt and a score of 100 indicates a country is perceived as very clean; ** the 
2012 CPI ranked 174 countries, where a lower rank indicates a cleaner country; *** the 2016 CPI ranked 176 
countries, where a lower rank indicates a cleaner country.  

Another  weakness  in  the  Romanian  healthcare  system  is  the  relatively  low  salaries  for 
healthcare providers (compared to other professions in Romania and compared to doctors 
and  nurses  in  other  European  countries),  in  combination  with  the  low  status  of  medical 
work and unfavourable working conditions and career development opportunities.  

For example, in 2015, some 13 500 physicians were working in Romanian hospitals, which 
has been calculated as about half the number actually needed. This is, to a large extent, 

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due to a high rate of migration to other countries.106 Wages that start at EUR 250 a month 
and  top  out  at  EUR  500  incentivise  many  to  go  abroad,  or  accept  additional  informal 
payments or other forms of irregular salary supplements.  

In comparison with other European countries, Romania ranks low in the general quality of 
healthcare  and  high  in  perceived  levels  of  healthcare  corruption.  For  example,  Romania 
ranks lowest out of all European countries on the Euro Health Consumer Index of 2016.107 
And according to the Special Eurobarometer 397 (published in 2014), Romania emerged 
as  be  the  EU  country  most  prone  to  bribery  in  medical  service  delivery.  In  response  to 
question QB2 – “Apart from official fees did you have to give an extra payment or a valuable 
gift to a nurse or a physician, or make a donation to the hospital? – 26% of interviewees 
answered  ‘yes’,  with  an  additional  4%  of  spontaneous  refusals,  which  are  the  highest 
scores across Europe (Figure below).  

Figure 3.1 Bribery in Medical service delivery (Special Eurobarometer 2014) 
Question B2. Apart from official fees did you have to give an extra payment or valuable gift to a nurse or a 
doctor, or make a donation to a hospital?  

Answers from countries with ‘yes’ above European average 

Romania

Lithuania

Hungary

Greece

Slovakia

Bulgaria

Latvia

Germany

EU average

0%

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Yes

Refused

No and don't know

Source: Special Eurobarometer 397, 2014 (fieldwork February – March 2013), p.89.  

The  special  Eurobarometer  also  contextualises  corruption  in  healthcare  within  other 
sections of Romanian society and compared to the EU averages. Figure 3.2 shows that the 
perceived levels of corruption in Romania are highest in healthcare (67%) and the police 
(67%) – and are much higher than EU averages.  

106 See http://www.politico.eu/article/for-paper-hold-til-wed-romanian-victor-ponta-surgery-european-health-
care-prime-ministers-surgery-abroad-raises-eyebrows/.  
107 See http://www.healthpowerhouse.com/en/news/euro-health-consumer-index-2015/. 

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Figure 3.2 Perceived levels of corruption in Romania, compared to EU averages 

Banks, financial institutions

Private companies

Inspectorates

Education

Healthcare

Business permits

Building permits

Tendering authorities

Political parties

Politicians

Public prosecutors

Social security

Courts

Tax authorities

Police

0

10

20

30

40

50

60

70

80

Source: Ecorys, data from Special Eurobarometer 397, 2014.  

EU 28 average

Romania

High levels of corruption and relatively low (and mixed) levels of the quality of the services 
are strongly intertwined. Corruption affects the quality of services, as resources are drained 
from  the  provision  of  healthcare  services.  In  addition,  problems  with  the  quality  of  the 
medical system also stimulate corruption.  

3.6.3.  Types of corruption in the healthcare system 
The  striking  features  about  corruption  in  the  Romanian  healthcare  system  are  that  (a) 
corruption  is  widespread,  and  occurs  among  all  corruption  in  healthcare  typologies  as 
described in the previous study on corruption in the European healthcare system, on behalf 
of DG HOME. In addition (b) the debate on corruption in healthcare in Romania is being 
conducted  very  openly,  with  healthcare  corruption  cases  appearing  regularly  in  the 
headlines  of  the  national  press,  and  high-profile  cases  being  actively  investigated  and 
prosecuted by the National Anticorruption Directorate DNA.  

Corruption in healthcare occurs in Romania in relations across all types of stakeholders in 
the healthcare sector, such as: the widespread practice of informal payments in order to 
get access to (better) medical treatment or to obtain false medical certificates providing 
entitlement to social benefits (between patients and healthcare providers), the occurrence 

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of  double  practice  (patients,  healthcare  professionals,  and  hospitals),  procurement  of 
medical devices (involvement of industry and payers), authorisation and procurement of 
pharmaceuticals (also involvement of industry and payers), corruption in the appointment 
of hospital or MoH managers, and corruption within the healthcare educational system. 
Other forms of corruption in the healthcare system are, for example: illegal sponsorship 
(sponsorships  are  not  illegal  per  se,  but  bribes  and  conflicts  of  interests  are  sometimes 
hidden  in  sponsorships)  with  several  high-profile  investigations  relating  to  this  practice, 
and  parallel  exports  (doctors  prescribing  medicines  to  their  patients  without  delivery; 
medicines are sold to other EU countries, at higher prices). 

Nicolae (2016) stipulates that corruption occurs at every layer of the Romanian healthcare 
system108, from the highest level of policymaking to mid-level policy implementation, up 
to the day-to-day level of the provision of healthcare services.  

Policy making 

At the highest level, corruption patterns resemble ‘state capture’, involve misuse of (high) 
level  positions  and  undue  influence  over  health  care  regulations,  corruption  related  to 
privatisation decisions, and the allocation of large funds.  

The Hospital case109 
On  9  December  2016,  DNA  –  the  anti-corruption  Bureau-  brought  in  a  former  Hospital  Manager  for 
questioning.  The  former  manager  of  the  Hospital  was  suspected  of  embezzlement  of  the  hospital  budget 
through cash withdrawals’. Total amount embezzled was estimated to be 2 million RON (EUR 430,000). The 
manager asked his subordinates to produce false invoices and bills for services that were never provided, to 
cover the missing money. 

The former manager was also accused of asking a company benefiting from hospital contracts to cover some 
470 trips for the manager and colleagues. The firm provided plane tickets, accommodation, restaurant meals 
and rental cars worth some 800,000 RON (EUR 178,000).  

Besides  these  formal  accusations  of  embezzlement  and  bribery,  which  are  under  investigation  by  DNA, 
investigative journalists have obtained evidence that the manager was involved in other scandals as well. For 
example,  the  manager  invited  several  politicians  to  the  opening  of  a  new  nursing  home.  The  manager 
apparently obtained money for this nursing home using his foundations, which claimed to be affiliated to the 
Knights of Malta. The nursing home was closed a day after the official opening.  

Policy implementation 

At policy implementation level corruption patterns involve a wide variety of modus operandi 
including  procurement  of  medical  equipment,  authorisation  and  procurement  of 
pharmaceuticals,  but  also  corruption  in  the nomination  of  managers or  in the  university 
system.  

Procurement of medical devices  

Procurement  of  medical  devices  may  take  many  forms,  as  the  payment  of  kickbacks  to 
hospital managers or government officials for the selection of a specific company, meddling 
with  the  quantities  ordered  or  prices  that are  being  paid.  There  are  also  cases  in  which 
hospital managers buy state-of-the-art equipment (in return for a kickback), that is not 
needed or where the hospital does not have the staff to operate it. Many cases are known 
where significant amounts of are spent on equipment that is never used. According to a 
recent  estimate  by  the  President  of  the  National  Agency  for  Public  Procurement  (ANAP) 
about  25  to  30%  of  public  procurement  contracts  are  suspected  of  fraud  or  corruption, 

108 Radu, N. (2016), ‘Healthcare corruption – patterns and vulnerabilities in Romania’.  
109 http://www.romania-insider.com/hospital-manager-romania-arrested-bribery-embezzlement-journalistic-
investigation/.  

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including the common practice of splitting large contracts in order to avoid the obligation 
to an open call for tender.110  

Authorisation and procurement of pharmaceuticals 

Pharmaceutical lobbying is a common practice in Romania. Pharmaceutical companies try 
to get on a governmental list of subsidised drugs. When they are on the list, the companies 
encourage  physicians  to  prescribe  their  drug.  Physicians  are  willing  to  do  that,  as  they 
receive additional payments from the pharmaceutical companies. They even prescribe the 
drug  in  cases  where  it  is  not  needed  (the  patient  has  another  disease).  The  drugs 
prescribed  are  often  expensive  and,  as  a  result,  take  money  from  the  public  healthcare 
budget.  

Appointment of hospital managers 

In general, the Romanian healthcare system is still characterised by a clientelist system of 
nomination  and  promotion  of  hospital  managers,  MoH  and  NHIH  officials.111  The 
supervision of hospitals in Romania is divided between various players. Several hospitals 
fall  under  the  competence  of  the  Ministry  of  Health,  while  many  others  fall  under  the 
competence  of  other  Ministries,  such  as  the  Ministry  of  Internal  Affairs,  the  Ministry  of 
Transport,  the  Ministry  of  Defence,  etc.  There  are  also  hospitals,  which  fall  under  the 
supervision of local councils.  

The Ministry or council responsible for the hospital is also responsible for appointing the 
management. Each Ministry and council therefore has a large influence on the appointment 
of the hospital manager and other staff on the board. The appointment procedure is unclear 
and  it  is  often  vague  on  what  grounds  a  person  is  appointed,  making  nepotism  and 
favouritism possible. In 2016, the Government adopted an emergency ordinance to combat 
this type of corruption. The previous government (which ruled until 11 December 2016) 
aimed to radically change the system of appointing hospital managers. However, the newly 
elected government, until now, has no intention to further implement the proposed system. 

Corruption in the healthcare education system 

Corruption  is  widespread  in  the  education  system  for  physicians.  Medical  students  learn 
from the start that if they want to achieve certain goals, they have to bribe their professors. 
In order to pass certain exams or obtain a position an intern at a certain department in the 
hospital, money needs to be paid.  

Healthcare professionals 

Corruption strategies by healthcare professionals in order to cope with the system and/or 
to supplement their salaries, or simply ‘profit from the system’s vulnerabilities’ may involve 
a  wide  variety  of  activities,  such  as:  reimbursement  for medical  activities  that have not 
been taken place; false prescription of medicines; directing patients to specific pharmacies 
(in  exchange  for  a  kickback);  reimbursements  on  inflated  patients  lists  (fake  names); 
reporting fictitious medical services and patients by hospitals; corruption in human organ 
and  egg  donation  (see  box  text);  corruption  in  clinical  testing;  informal  payments  for 
(better) treatment; informal payments for illegitimate disability certificates; and corruption 
in double practices.112 

Control bodies reports on irregularities within the National Transplant Agency113 

110 ttps://www.romania-insider.com/one-four-direct-hospital-procurement-contracts-romania-suspicious/.  
111 Radu, N. (2016), ‘Healthcare corruption – patterns and vulnerabilities in Romania’.  
112 Radu, N. (2016), ‘Healthcare corruption – patterns and vulnerabilities in Romania’. 
113 Website :Ministry of Health -23 November 2016.  

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The Ministry of Health commissioned the Control Body to investigate the National Transplant Agency and its 
related hospitals that are accredited to conduct organ transplants. During a sample in which four accredited 
hospitals  were  checked  it  became  clear  that  in  all  four  hospitals,  procedures  were  not  followed  and  the 
minimum criteria set out in law were not enforced. Based on the 100% result, the Ministry decided that all 
active  transplant  centres  in  the  country  need  to  be  checked  thoroughly  in  order  to  see  whether  more 
irregularities can be detected.  

The Control Body also showed that the criteria for allocation of organs to patients who need a transplant are 
not clear, and that the National Transplant Agency does not register organs available for transplant, even 
though a legal obligation to develop one overall register exists. As a result, each hospital still has its own list 
for organ transplantation and uses its own waiting times, instead of using one nationwide list. Thus Law 95 
of 2006 is violated which clearly states that the National Transplant Agency manages the national registers, 
which provide continuous monitoring of transplant activities.  

Informal payments 

Informal  payments  are  one  of  most  common  types  of  corruption  in  Romania.  Informal 
payments are to a certain extent motivated by the fact that patients are accustomed to 
offering gifts after services (n particular older patients and in more rural areas). However, 
payments are offered in advance in exchange of (faster) access to healthcare, access to 
better  healthcare,  or  in  exchange  of  a  false  certificate  that  entitles  the  patient  to  social 
benefits such as sickness leave, disability and early retirement. Informal payments do not 
only involve physicians, but extend to all hospital related staff. Nurses, catering people and 
cleaners may also receive money for services provided.  

Double practice 

Double  practice  occurs  frequently  in  Romania.  Double  practice  is  not  against  the  law: 
physicians are allowed to increase their income with private money earned during evening 
and weekend hours. However, there are several cases in which physicians make use of the 
infrastructure of public hospitals for their private (double practice) activities, and are being 
paid for this by the NHIF.114 When making use of a double practice medical service, the 
patient  pays  twice  for  the  same  service;  via  their  mandatory  health  insurance  (to  get 
hospital access) and directly to the physician (who uses the same hospital facilities, which 
are already paid for). The patients that are able to pay for the ‘private’ treatment face lwer 
waiting times.  

Visual proof double practice 
One of the hospitals in Bucharest is visibly linked to a private clinic, by a bridge. Patients in the private clinic 
are treated in the hospital, while paying private clinic prices. The clinic is mainly used as a recovery centre 
(i.e. hotel). The facilities in the hospital are not used for patients who cannot afford private care.  

A  specific  feature  of  (the  fight  against)  healthcare  corruption  in  Romania  is  the  regular 
stream  of  corruption  cases  that have  been  disclosed  or described  by  the press  over the 
past few years and the attempts to actively investigate and prosecute corruption in general, 
including healthcare corruption. A few high-profile cases, such as the disinfectants scandal 
revealed by investigative journalists, caused much public outcry.  

Pharmaceutical case after fire in a night Club 
This scandal started with a fire in a night Club, which took place at the end of October 2015. In its wake, the 
fire left a trail of 64 dead people. Several of them died during the fire, while others died during their stay in 
hospital. Although most of the patients died of their wounds, five patients died because of the usage of diluted 
disinfectants. 

Romanian  investigative  journalists  dug  deeper  into  the  matter  and  discovered  that  the  use  of  diluted 
disinfectants was widespread in the Romanian health system. The Romanian state purchased these diluted 
disinfectants for hospitals across the country from a pharmaceutical company that had already been involved 
in a similar scandal in 2006, at prices that were ten times higher than prices asked by other suppliers.  

114 Radu, N. (2016), ‘Healthcare corruption – patterns and vulnerabilities in Romania’.  

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Analysis of DNA cases 

Romania’s National Anti-Corruption Directorate (DNA) has increasingly targeted high-level 
corruption  since  2007,  when  intensive  EU  monitoring  was  introduced  through  the 
Cooperation and Verification Mechanism (CVM) Reports.115 The research team received a 
file of 54 cases of corruption in healthcare that have been under investigation by DNA since 
2012 (closed and on-going cases). An analysis of file reveals a steady annual increase in 
the number of cases that have been opened: from 3 in 2012 to 23 cases in 2016: 

Table 3.4 Number DNA cases involving corruption in healthcare (2012-16) 

Yeart 
2016 (up until November 2016) 
2015 
2014 
2013 
2012 
Total 

Source: National Anti-Corruption Directorate (DNA).  

# of cases 
23 cases 
14 cases 
11 cases 
3 cases 
3 cases 
54 cases 

An  analysis  of  the  ‘typologies’  of  corruption  in  healthcare  of  these  54  cases  (along  the 
typologies  defined  in  the  first  study  on  corruption  in  the  European  healthcare  system), 
reveals that DNA has investigated and prosecuted particularly high level cases and cases 
related to policy implementation. The health system in Romania is captured at the policy 
making  level,  excessive  bureaucracy,  poor  management,  and  loopholes  deliberately  not 
challenged and even developed in order to drain resources and maintain status-quo.  

The  underlying  charges  show  a wide  variety  of  offences,  often  a  combination  of  several 
offences, such as ‘creation of an organised crime group’ in combination with ‘complicity to 
giving bribe’ and ‘complicity to abuse of office’. 

Table 3.5 Typologies of DNA cases involving corruption in healthcare (2012-16) 

# of cases 
33 
18 
13 
12 
6 
1 

Typology 
Misuse of high-level positions 
Procurement corruption 
Bribery in medical service delivery 
Fraud (various forms) 
Undue reimbursement claims 
Improper marketing relations 
Types of offences (more than 1 per case possible): Bribe giving (complicity to) 10; Bribe taking 
(complicity to) 39; Abuse of office (of which 3 with extremely serious consequences) 19; 
Influence peddling / buying influence 15; Conflict of interests 3; Conducting financial transaction 
incompatible with job description 2; Tampering with official documents 2; Use of false 
documents 7; Creating false documents 8; Forgery 4; Fraud (complicity to) (of which 1 
regarding the quality of goods) 4; Using or presenting bad faith 1; Receipt and sale of stolen 
goods 1; Creation of an organised crime group 1; Money laundering 2; Instigation to false 
statements 1; Instigating to forgery documents under private signature 1; Aiding and abetting 
the perpetrator 1; Allow access to unauthorised information 1. 

Level 
Policy making 
Policy implementation 
Healthcare professionals 
Policy implementation 
Policy implementation 
Policy implementation 

Source: Ecorys’ analysis, based on National Anti-Corruption Directorate (DNA). 
More than one typology per case possible. 

3.6.4.  Recent policy developments 
Since  the  2013  (SCH1)  publication  several  policy  initiatives  have  been  taken  up  by  the 
Romanian government. The main ones are policies on: 

115 See e.g. http://ec.europa.eu/dgs/home-affairs/what-we-do/policies/organized-crime-and-human-
trafficking/corruption/anti-corruption-report/docs/2014_acr_romania_chapter_en.pdf.  

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Introducing co-payments; 

 
  Taxation of bribes; 
  Adopting an anti-corruption policy; 
Increasing transparency in the appointment of hospital managers; 
 
Introducing a special phone line; 
 
  Uptake of the electronic health card; 
  Wage increases for medical staff.  

Policy to introduce co-payment 

Legalising  informal  payments  by  creating  a  co-payment  system,  was  one  of  the  priority 
policies  of  the  large  healthcare  reform  program  that  started  in  2006.  In  the  original 
proposal, which was supported by the World Bank, it was proposed that patients needed 
to  pay  a  small  contribution  for  receiving  care  (5  EUR  for  a  family  doctor,  10  EUR  for  a 
specialist physician and 10 EUR per day for a hospital admission). It was estimated that 
this  system  would  generate  340  million  EUR  annually,  an  amount  equal  to  the  informal 
payments currently paid.  

The initiative has been long debated in the Romanian Parliament. The law was drafted in 
2010 and adopted in 2011. The policy was changed twice in 2012 and finally adopted in 
April 2013. By then, the co-payment regime had changed. A co-payment only has to be 
paid  in  case  of  hospital  admissions,  and  has  a  value  between  5  –  10  RON  (1  –  2  EUR) 
irrespective of the number of days admitted. Also, many exemptions have been introduced. 
Patients  exempted  are  pregnant  women,  children,  students,  pensioners  with  an  income 
lower than 740 RON and the unemployed. As a result, the additional income generated by 
physicians  and  hospitals  is  low.  In  addition,  the  distribution  of  the  additional  income  is 
unequally  divided,  with  some  hospitals  receiving  quite  a  significant  sum  of  additional 
money, while for others, especially the small local hospitals the additional income is less 
than 25 EUR on a yearly basis.  

It could be concluded that this policy has failed. On the one hand, the co-payments are 
low and therefore do not generate much additional income; on the other hand, patients 
still pay physicians informally. As a result, patients make an informal payment twice rather 
than just once. It should be noted that besides the informal payments, patients also pay 
via their insurance to the healthcare system. Although this policy initiative has failed, the 
government is not planning to change it.  

Policy to tax bribes 

A policy initiative linked to the policy of introducing a system of co-payments is the taxation 
of bribes.116 The government and several MPs proposed, in 2015, to impose taxation on 
the  bribes  received.  Although  this  proposal  was  heavily  criticised,  it  is  still  pending  in 
Parliament.  The  general  public  holds  mixed  views  with  regard  to  paying  bribes  and  the 
potential taxation of bribes. During a recent survey conducted by the Ministry of Health117 
46% of the respondents indicated that bribes should not exist, while another 46% indicated 
that bribing is an entrenched practice. 22% believe that paying informal payments are a 
form of reward, while 10% indicated that giving gifts is normal for them, and nothing has 
changed.  

Adoption of the National Anti-Corruption Strategy 

On  10  August  2016,  the  new  National  Anti-Corruption  Strategy  (NAS)  2016-2020  was 
adopted,  building  upon  the  previous  anti-corruption  strategy  covering  the  years  2012-
2015.  Approximately  90  public  institutions,  non-governmental  organisations,  business 

116 Prime-Minister declarations: Romania considers legalizing bribery to keep doctors by Vlad Odobescu – The 
Washington Times- Tuesday, October 6, 2015. 
117 Radu, N. (2016), ‘Healthcare corruption – patterns and vulnerabilities in Romania’. 

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association  as  well  as  state-owned  and  private  companies  were  involved  in  the 
development of the new strategy. 

In  addition  to  six  overall  objectives  (develop  a  culture  of  transparency,  increase 
institutional integrity, strengthen integrity and reduce corruption risks in priority sectors, 
increase awareness and understanding, consolidate performance in combating corruption 
through criminal and administrative means, increase the recovery of proceeds of crime), 
specific  actions  for  the  healthcare  sector  (as  one  of  the  priority  sectors)  have  been 
formulated. These actions include: 
1.  Create a mechanism with a clear prioritisation of budgetary allocations and assessment 

(evaluation) of the decisions and their implementation;  

2.  Enhance transparency of the use of public resources, by centralised aggregation of data 

on the portal transparenta.ms.ro; 

3.  Evaluate the performance of the centralised procurement system of the MoH; 
4.  Create  within  the  MoH  and  NHIH  a  joint  mechanism  for  monitoring  and  controlling 

suppliers in the social health insurance system;  

5.  Create a mechanism for the traceability of medicines on the Romanian market; 
6.  Strengthen  the  control  and  integrity  structures  within  the  MoH  and  extend  their 

competence; 

7.  Improve  accountability  mechanisms  for  managers  and  other  decision  makers  in 

hospitals; 

8.  Develop  a  new  mechanism  for  the  financial  support  of continuous medical  education, 
with a view to eliminating sponsoring by the pharmaceutical industry and sponsoring by 
medical equipment suppliers to the benefit of the medical staff;  

9.  Identify the situations which can generate conflicts of interest among the clinical and 

managerial staff; 

10.  Review the patient feedback mechanism. 

The estimated necessary budget for implementing those actions is 19.800.000 Lei (approx. 
4.3 million EUR). Main responsible institutions are the Ministry of Health and the National 
Insurance House. Actions 2 – 5, 9 and 10 needed to be realised by the end of 2016. Actions 
1, 6 and 7 should be completed before the end of 2017 and action 8 should be finalised by 
the end of 2018.  

MoH Integrity department 

As  mentioned  in  the  initial  study  on  Corruption  in  the  Healthcare  Sector,118  in  2011,  an 
Integrity  Department  was  set-up  in  the  Ministry  of  Health.  This  department  has  the 
responsibility to develop and implement strategies to fight corrupt practices and counter 
corruption risks within the healthcare system. Romania’s National Reform Programmes of 
2015 and 2016 under the Europe 2020 Strategy, mention a number of healthcare reforms 
undertaken  with  the  aim  of  reducing  informal  payments.119  One  of  the  reforms  was  the 
singing of a financing agreement under the European Social Fund for ‘Good Governance 
through Integrity and Responsibility in the Health System’. The aim of the agreement is to 
develop  a  coherent  policy  to  combat  corruption  in  the  healthcare  system,  with  special 
assistance from the Ministry of Health’s Integrity Department. In addition, more staff for 
the  Integrity  Department  were  hired  and  a  complaints  monitoring  system  was  adopted. 
Measures to be implemented in 2017 are a corruption risk analysis in all medical structures, 
monitoring of public procurement, monitoring of hospitals spending, and implementing a 
patient feedback mechanism.120 

118 Study on Corruption in the Healthcare Sector, 2013, p.296. 
119 See http://ec.europa.eu/europe2020/pdf/csr2015/nrp2015_romania_en.pdf.  
120 http://ec.europa.eu/europe2020/pdf/csr2016/nrp2016_romania_ro.pdf. 

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Increasing transparency in the appointment of hospital managers 

In addition to the adoption of the NAS 2016-2020, the Government adopted an emergency 
ordinance (EO no. 79/2016) which aims to modify the selection of hospital managers.121 
The  ordinance  states  that  managers  should  be  selected  through  open  competition,  and 
thereby reducing the charge on favouritism. In addition, the ordinance also extends the 
list  on  potential  conflicts  of  interests  to  a  wider  category  of  hospital  management  staff. 
Early  in  2017,  the  ordinance  was  rejected  by  the  Senate.  In  May  2017  the  Chamber  of 
Deputies  overruled  the Senate  decision  and  adopted  the  law  approving EO  79/2016  but 
repealing  certain  key  anti-corruption  provisions  regarding  conflicts  of  interest  and 
incompatibilities  between  management  positions  and  political  affiliations.  The  Romanian 
president refused to promulgate the law and sent it back to Parliament in June 2017 for 
re-examination. The Senate is expected to start the re-examination process beginning in 
September 2017. 

Introduction of a phone line to report corruption 

Another recent initiative – introduced in December 2016 - was the introduction of a special 
phone line where patients, doctors or witnesses of corruption cases can report on potential 
breaches,  including  public  procurement  suspicions.122  Setting  up  the  phone  line  was  an 
initiative of the Ministry of Health. The system is managed by the General Anti-Corruption 
Directorate (DGA). DGA provides the Ministry of Health with data analysis, reports, case 
studies and other relevant material, and the Ministry can take further action if necessary.  

Uptake of the electronic health card 

An initiative that seems to be more effective is the use of the electronic health card.123 This 
card  was  already  introduced  in  2015,  but  technical  failures  occurred  which  hampered  a 
successful introduction. System failures occurred throughout 2016, but their frequency is 
diminishing. The aim of the card is to reduce the opportunities for social insurance fraud. 
Due to the technical failures, it is currently not possible to assess its impact.  

Wage increase medical staff 

As of January 2016, a portal to monitor public procurement contracts was under way and 
a part of the procurement of goods is now centralised at Ministry level.124 Wages of medical 
personnel have been raised by 25%, which may be instrumental in reducing the incentive 
to  ask  for  informal  payments,  and  are  scheduled  to  be  doubled  in  2  to  3  years.  In  July 
2017, the new public sector wage law came into force (Law no. 153/2017). According to 
the new law, Romanian doctors’ and nurses salaries should double next year, with a 25% 
increase in January 2018 and the rest in March 2018. 

While there is common agreement that salaries are too low and the healthcare system is 
underfinanced,  which  are  the  main  factors  driving  the  exodus  of  Romanian  healthcare 
professionals, there is still doubt that the increase, in itself, will be enough to end a deeply 
entrenched culture of bribery.125 Moreover, the new law providing salary increases for all 
state employees, raises concerns about the budget deficit. 

The  government’s  intention  to  hike  the  salaries  of  medical  staff  has  sparked  debate  in 
Romania.  While  everyone  agrees  that  the  healthcare  system  is  underfinanced  and 
numerous doctors and nurses leave the country each year due to the low salaries, pundits 

121 SWD(2017) 25 final: Romania: Technical report (CVM). 
122 SWD(2017) 25 final: Romania: Technical report (CVM). 
123 SWD(2017) 25 final: Romania: Technical report (CVM). 
124 SWD(2017) 25 final: Romania: Technical report (CVM). 
125 Interviews for this study and http://www.business-review.eu/featured/government-approves-25-pct-salary-
increase-in-healthcare-system-86488.  

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argue  that  the  increase  by  itself  will  not  address  the  issue  nor  will  it  help  end  a  deeply 
entrenched culture of bribing. In addition, there are concerns that the public sector salary 
increases will raise the budget deficit. For the five months of 2017 the budget deficit was 
0,27%  of  GDP  according  to  the  Ministry  of  Finance  (three  times  more  than  in the  same 
period in 2016). Eurostat issued in July 2017 data confirming the deficit trend, Romania 
being on second place, after France, with a deficit of 3,2% of GDP in the first trimester of 
2017.  

National Agency for Public Procurement 

A new National Agency for Public Procurement has been set up, which will integrate control 
and verification procedures previously performed by two agencies, and will have a role in 
policymaking as well. 

Initiative to decriminalise corruption 
In  January  2017,  the  newly  established  Romanian  government  adopted  an  emergency  law  that,  should  it 
become effective, would decriminalise certain forms of corruption. The motivation for adopting this new law 
is  the  overcrowded  condition  of  Romanian  prisons.  Government  officials  indicated  that  decriminalising 
offences up to 200,000 LEI (EUR 45,000) per case, would lead to a substantial decrease in the number of 
prisoners, enabling the prisons to function in a more optimal way. Opponents to this new law suggested that 
this law would particularly benefit the new Prime Minister who is under investigation over abuse of power 
allegations and had also previously received a two-year suspended sentence for an elections offense. 

In addition to the above described initiative, the government also adopted a decree that would allow for the 
release of some officials who are currently in prison after being convicted for corruption.  

The new initiatives sparked a strong reaction from the Romanian public. Many people demonstrated against 
the  two  new  decrees  and  protested  for  several  days  throughout  the  country.  After  more  than  a  week  of 
severe  demonstrations,  the  Romanian  Minister  of  Justice,  who  is  responsible  for  the  two  new  decrees, 
resigned. Although the government announced that the decrees would not be implemented in their current 
form, they are still working on revised versions, which will be sent to Parliament shortly. 

The  European  Commission  expressed  its  concerns  over  the  situation  in  Romanian  stating  that  ‘The  fight 
against corruption needs to be advanced, not undone. We are following the latest developments in Romania 
with great concern.’126 

3.6.5.  Challenges and conclusions 
Corruption in healthcare is widespread and occurs in many different forms and at all levels 
of the healthcare system. On the positive side, there is an open debate on corruption, as 
over the past few years a large number of cases have been revealed by the authorities and 
by investigative journalists and widely debated in the press. Following a few high-profile 
scandals in recent years, corruption in healthcare has been brought to the attention of the 
public. Romania has made progress in fighting corruption in healthcare via criminal law, 
however the main challenge now will be to bring corruption in healthcare down via other 
preventive  measures.  The  new  National  Anti-corruption  Strategy  (NAS)  and  measures 
specifically targeted at the healthcare sector are a step in this direction.  

One major problem is the volatility of the National Health Insurance House (NHIH). The 
House  is  the  only  public  insurer  and  in  principle  all  Romanians  are  required  to  have 
insurance  provided  by  this  house127  The  National  House  is  supported  by  local  houses. 
Jointly they pay for medication and treatment however the municipalities, which receive 
the  money  from  the  Houses,  invest  in  equipment.  Municipalities  can  request  money  for 
investment, but once the money is transferred from the Houses to the municipalities, there 
are no further checks. It often happens that the municipalities do not use the money for 
the purposes for which they received it, and it is then lost in the system. In addition to the 

126 http://edition.cnn.com/2017/02/01/europe/romania-protests/.  
127 It is possible to obtain private insurance as well, but the private insurance is complimentary to the public 
insurance.  

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weak  financial  structure,  the  National  Health  Insurance  House  is  not  party  to  the  anti-
corruption strategy adopted for the healthcare system. They are one of the last few players 
not participating.128 

Recent government actions to reverse or stall several key reforms in healthcare, may prove 
a  serious  drawback  in  the  Romanian  fight  against  corruption.  Several  interviewees 
indicated that, since the start of 2017, many policies aiming to reduce corruption, including 
healthcare  corruption,  have  come  under  pressure.  In  February  2017,  the  new 
governmental majority faced the largest protests since the fall of Communism because of 
their agenda to repeal anticorruption reforms. 

While the previous (technocratic) government had a focus on preventing and combatting 
corruption  (in  the  healthcare  sector  by  increasing  the  number  of  inspections,  trying  to 
introduce  a  system  of  checks  and  balances,  and  changing  the  appointment  system  of 
hospital managers), this seems no longer under the attention of the new government. For 
example, in the new Governance program for the healthcare sector, combatting corruption 
is not mentioned and the word “corruption” is mentioned just twice in 62 pages.  

Besides the risks and obstacles described above, the risks identified during the SCH1 are 
still relevant: 

  Health sector rules and regulations are weak or non-existent; 
  Over-regulation; 
  Lack of accountability; 
  Limited offer of services (i.e., more demand than supply); 
  A poor representation of the social partners at the decision level of the National 
Health Insurance Fund, which renders the anticorruption guarantees ineffective 
or even eliminates them; 

  A broad asymmetry in information;  
  Aspects of inequity in the use of healthcare;  
  Lack  of  transparency  related  to  the  health  reforms  and  especially  in  terms  of 

the spending of public funds for health;  
  Considerable distrust in public institutions;  
  Poor access to health services in certain areas and groups;  
  Lack of consensus between policy/decision makers;  
 

Incrimination of corruption.  

Future  progress  of  Romania  in  its  fight  against  corruption  in  general  and  in  healthcare 
specifically will also depend on political will, and initiatives by the Romanian government. 
Independent investigative journalism will remain crucial in questioning illegal practices in 
the  healthcare  sector.  An  independent  and  critical  prosecutor’s  office  (DNA)  is  vital  in 
fighting corruption in a strict way. However, criminal law has its limits. Therefore, active 
prosecution of corruption cases should be paired with preventive measures, behavioural 
changes and structural reform of the healthcare sector.  

128 Although officially no reason for their non-participation is given, interviewees indicated that the House does 
not want to participate, as there is too much corruption within the House itself 

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4.  UPDATE SHC1 AND THEMATIC DEEPENING 

Introduction 

4.1. 
The Special Eurobarometer 397 serves as an important point of reference for this study: it 
was published in February 2014 and based on fieldwork in February and March 2013, which 
was parallel with the fieldwork of our initial study on Corruption in the European Healthcare 
Sector  (SHC1).  At  the  time  of  the  publication  of  the  SHC1,  the  results  of  the  special 
Eurobarometer  were  not  yet  made  public.  One  important  factor  included  in  the  Special 
Eurobarometer is the perception of corruption in each EU Member State. Respondents were 
asked whether they think that giving or taking bribes, and the abuse of power for personal 
gain  are  widespread  among  the  healthcare  sector.  The  answers  to  this  question  are 
presented below. 

Figure 4.1 Perceptions of corruption in healthcare (Special Eurobarometer 397, 2014) 
QB7 In (OUR COUNTRY), do you think that the giving and taking of bribes and the abuse of power for personal 
gain are widespread among healthcare? 

81

74

67

64

62

56

56

55

53

53

44

41

41

90

80

70

60

50

40

30

20

10

0

33

33

30

30

27

24

23

18

15

15

15

15

15

12

9

4

FI

SE

DK

BE

IE

LU

AT

UK MT

ES

FR

NL

DE

EE EU 28 PT

CZ

SI

IT

LV

PL

BG HU HR

CY

SK

RO LT

EL

Source: Special Eurobarometer 397, 2014 (fieldwork February - March 2013), Table QB12, p.97. 

The  top-10  countries  (with  the  highest  levels  of  perceived  healthcare  corruption)  are 
presented in Table 4.1 below. The Table shows that the focus countries for this study are 
ranked at levels 1, 2, 3, 6, 7 and 10, amongst countries with the highest levels of perceived 
healthcare  corruption  and  far  above  the  EU  average,  which  stands  at  33%  (detailed 
overview, see Annex IV). 

Table 4.1 Top-10 EU countries with highest levels of perceived Corruption in Healthcare 
(Special Eurobarometer 397, 2014) 
QB7 In (OUR COUNTRY), do you think that the giving and taking of bribes and the abuse of power for personal 
gain are widespread among healthcare? 

Rank 
1 
2 
3 
4 
5 
6 
7 

Country 
Greece 
Lithuania 
Romania 
Slovakia 
Cyprus 
Hungary 
Croatia 

% 
81 
74 
67 
64 
62 
56 
56 

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8 
9 
10 
EU average 

Bulgaria 
Latvia 
Poland 

55 
53 
53 
33 

Source: Special Eurobarometer 397, 2014 (fieldwork February - March 2013), Table QB12, p.97. 

Corruption in healthcare is not an isolated phenomenon. In Figure 4.2, the perceptions of 
corruption  in  healthcare  are  compared  with  the  general  perceptions  of  the  existence  of 
corruption.  The  figure  reveals  that,  in  general  perceived  corruption  in  healthcare  is 
correlated  with  general  levels  of  perceived  corruption.  Greece,  Lithuania,  Romania, 
Slovakia, and Cyprus are among the countries with both the highest levels of perceived 
general  corruption  and  specific  healthcare  corruption,  while  on  the  other  side  of  the 
continuum the Scandinavian countries score well of both indicators. 

Figure 4.2 Correlation between perceptions of corruption in healthcare and general 
corruption 

Source: Ecorys 2016, derived from Special Eurobarometer 397, 2014 (fieldwork February - March 2013), Table 
QB7 and QB5. 

4.2.  Update SCH1 
In the initial study on Corruption in the Healthcare Sector (SCH1), 13 general conclusions 
were drawn: 
1.  Convictions of (high-profile) corruption cases have a deterrent and norm-setting effect 
2.  Centralisation of procurement is a method to lower the risks of corruption 
3.  Central procurement systems can become vulnerable as targets for lobbyist and more 

politically inspired types of corruption 

4.  Bribery  in  medical  service  delivery  cannot  be  contested  with  only  targeted  policies 
against  the  phenomenon  as  such,  but  need  to  be  supplemented  with  accompanying 
(structural) measures 

5.  Raising  salaries  does  not  have  a  significant  preventive  effect  on  reducing  bribery  in 

medical service delivery 

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6.  The  root  causes  of  corruption  in  healthcare  are  related  to  (i)  ineffective  managerial 
structures,  (ii)  inappropriate  financing  mechanisms,  (iii)  insufficient  health  care 
capacity,  (iv)  insufficient  funding  for  independent  medical  research,  (v)  unequal 
allocation of resources and (vi) a general acceptance of corruption in society 

7.  The introduction of transparent waiting lists has a positive effect on reducing healthcare 

bribery 

8.  Prescription of generics instead of branded pharmaceutical products has a positive effect 

on reducing healthcare bribery 

9.  Self-regulation  between  the  industry  and  healthcare  providers  is  needed  to  fight 

corruption in healthcare 

10. 

Self-regulation  among  players  (such  as  within  the  pharmaceutical  industry  or 

among physicians) is needed to fight corruption in healthcare 

11. 

Awareness  raising  campaigns  and  fraud  and  corruption  reporting  hotlines  are  an 

effective instrument to fight corruption in healthcare 

12. 

The government should play a (more) active role  in creating transparency in the 

relations between the industry and healthcare providers 

13. 

The  importance  of  active  –  independent  –  media  involvement  and  pressure  from 

‘civil society’ watchdogs is essential to fight corruption in healthcare. 

During this study, stakeholders were asked whether they believe that these conclusions 
are  still  relevant.  In  order  to  collect  information,  the  conclusions  were  included  as 
statements in the survey and interviewees were also asked their opinion during the fact-
finding  missions.  To  further  complete  the  information,  the  conclusions  were  discussed 
(whenever relevant) during the EU-level interviews.  

In the following sections, we present the results of the survey, the fact-finding missions 
and EU-level interviews per conclusion. For the analysis of the survey results, the answers 
are bundled into geographical groups. It should be noted that not all EU-28 Member States 
are included in the different groups, as we did not receive responses from all countries. 
We received answers from 19 Member States129. 

The following groups have been defined, with the total number of respondents per 
category indicated in brackets:130  
  Group 1- Mediterranean [10] 

o  consisting of Italy, Spain, Portugal and Croatia  

  Group 2 - Eastern Europe [16]  

o  consisting  of  Slovenia,  Czech  Republic,  Estonia,  Latvia,  Lithuania, 

  Group 3 - North West Europe [18]  

Romania and Bulgaria 

o  consisting of Austria, Belgium, Denmark, Finland, France, Germany, the 

Netherlands and the United Kingdom. 

4.2.1.  Conclusion 1: Convictions of (high-profile) corruption cases have a 

deterrent and norm-setting effect 

Survey results 

In  the  survey,  a  total  of  31  respondents  indicated  whether  they  agree  with  the  first 
conclusion of the SHC1 study. In the Table below, the results per answering category are 
presented. As can be seen, the majority of the stakeholders (65%) agree that convictions 
in  (high-profile)  corruption  cases  have,  at  least  to  some  extent,  a  deterrent  and  norm-

129 Countries from which we did not receive responses are: Cyprus, Greece, Hungary, Ireland, Luxembourg, 
Malta, Poland, Slovakia and Sweden. 
130 An overview of the respondents per country can be found in Section 2.2 above. 

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setting effect. It is interesting to see that only 10% (3 respondents in total) disagree with 
this conclusion. 25% of the respondents answered that they do not know. 

Table 4.2 Answers to statement #1 (n=31) 

Convictions in (high-profile) corruption cases have a deterrent and norm-setting 
effect (n=31) 
Yes 
To some extent 
Not 
Do not know 

9 
11 
3 
8 

In  the  Figure  below,  the  geographical  spread  for  each  of  the  three  defined  regions  is 
presented. It appears that in Eastern Europe, none of the stakeholders indicated that they 
disagree  with  the  conclusion;  however,  the  share  of  respondents  not  knowing  whether 
convictions will have a norm-setting effect is also the highest in this region. 

Figure 4.3 Geographical spread conclusion #1 (n=31) 

The number of respondents in each group: n= 7 (group 1), n= 13 (group 2), n= 11 (group 3). 

Fact finding missions 

Greece:  Most  Greek  stakeholders  indicated  that  convictions  in  (high  profile)  corruption 
cases  have  a  norm-setting  effect,  at  least  to  some  extent.  However,  it  should  be  noted 
that in Greece hardly any cases of corruption are brought to court. On the one hand, this 
is caused by the fact that many cases are not reported and / or investigated. On the other 
hand, cases that are investigated are often not brought to court due to major backlogs in 
the judicial system. Some stakeholders indicated that it could take between 10 – 15 years 
before a case can be brought to court. 

Croatia: Stakeholders in Croatia agreed that convictions of high-profile corruption cases 
have a deterrent and norm-setting effect on combatting corruption. 

Lithuania: Overall, most stakeholders agreed with the statement that convictions of high-
profile corruption cases have a deterrent and norm-setting effect on combatting corruption. 
However,  one  stakeholder  mentioned  that  he/she  was  unsure  whether  this  applies  to 
Lithuania, as experience in some areas is limited; in 2016, two physicians were convicted 
for bribery  and this was the first time in history that this happened. The hope was that 
these cases would serve as an example for the future.  

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Hungary: The Hungarian stakeholders interviewed agreed that convictions of high-profile 
cases would have a deterrent and norm-setting effect, but remarked that this had not yet 
happened in Hungary.  

Poland: All stakeholders agreed that convictions of high-profile corruption cases have a 
deterrent and norm-setting effect on combatting corruption.  

Romania: Overall, stakeholders did agree with the statement that convictions have a norm 
setting  effect.  DNA,  the  anti-corruption  bureau,  is  seen  as  a  success  factor  in  the  fight 
against  corruption.  The  high  number  of  cases  investigated  and  prosecuted  by  DNA, 
specifically focused on high-profile people (both politicians and physicians), is seen as value 
added. The appointment of the current chief prosecutor (2013) has further increased the 
effectiveness of DNA, according to the stakeholders interviewed. 

EU-level interviews 

Speaking  in  a  personal  capacity,  representatives  of  MedTech  Europe,  the  International 
Association of Mutual Benefit Societies (AIM) and ASSPRO (an EU joint research project) 
agreed  that  convictions  can  be  effective,  with  the  nuance  made  by  AIM  that  it  is  only 
effective when followed up by sustained political action. 

4.2.2.  Conclusion 2: Centralisation of procurement is a method to lower the 

risks of corruption 

Survey results 

The conclusion of the SHC1 study that centralisation of procurement is a method to lower 
the risks of corruption is supported by the majority of the stakeholders responding to the 
survey.  Out  of  31  respondents,  20  (65%)  indicated  that  they  agree,  at  least  to  some 
extent,  with  this  statement.  Five  respondents  (16%)  indicated  that  they  do  not  see 
centralised procurement as a method to reduce the risks of corruption. 

Table 4.3 Answers to statement #2 (n=31) 

Centralisation of procurement is a method to lower the risks of corruption (n=31) 
Yes 
To some extent 
Not 
Do not know 

12 
8 
5 
6 

In  the  Figure  below,  the  geographical  spread  is  presented.  Notably,  almost  half  of  the 
respondents from the Mediterranean area are of the opinion that centralised procurement 
is not a suitable method to reduce the risks of corruption. In contrast, the majority of the 
respondents from Eastern Europe (84%) indicated that centralised procurement is at least 
to some extent a solution. Respondents from North West Europe represented the largest 
group of respondents who do not know whether centralised procurement is a solution. The 
strong division between the three regions might be explained by the current experiences 
in  public  procurement,  with  the  Mediterranean  and  Eastern  Europe  experiencing  higher 
levels of procurement corruption than North West Europe. 

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Figure 4.4 Geographical spread conclusion #2 (n=31) 

The number of respondents in each group: n= 7 (group 1), n= 13 (group 2), n= 11 (group 3). 

Fact finding missions  

Greece: Many of the stakeholders consulted indicated that central procurement could be 
a good method to lower the risks on corruption. It should, however, be noted that in Greece 
some  initiatives  for  central  procurement  have  already  been  undertaken.  For  instance,  a 
central  procurement  committee  has  been  established,  but  is  perceived  as  not  effective. 
Since its establishment, only one public procurement process was started, and this took 
several  years.  Public  procurement  processes  take  over  three  years  before  they  are 
concluded. In addition, since the economic crisis hardly any tenders have been procured, 
due to a lack of budget.  

Croatia: Croatian stakeholders interviewed by the study team agreed that centralisation 
of  procurement  is  a  method  to  lower  the  risks  of  corruption.  The  representative  of  the 
pharmaceutical association mentioned that it is also important to have (public) registries 
of products and prices. 

Lithuania:  The  opinions  in  Lithuania  regarding  this  statement  were  divided:  multiple 
stakeholders  did  not  agree  with  the  statement  that  centralisation  of  procurement  is  a 
method to lower the risks of corruption, while others did agree. One stakeholder partially 
agreed.  It  was  noted  by  several  stakeholders that  in  both  centralised  and  decentralised 
procurement systems there are risks for corruption. 

Hungary: Hungarian stakeholders did not agree that centralisation of procurement would 
lower  the  risk  of  corruption.  On  the  contrary,  if  not  accompanied  by  transparency-
increasing measures, it has the opposite effect.  

Poland: Polish stakeholders agreed that centralisation of procurement is a method to lower 
the risks of corruption. Stakeholders mentioned that the current decentralised procurement 
system might lead to problems, especially in smaller hospitals, where not enough technical 
knowledge is available to formulate proper tender specifications. As a solution, they ask 
the suppliers of medical equipment for more information and for help in writing the terms 
of reference, which can lead to improper tendering.  

Romania:  The  majority  of  the  stakeholders  agreed  that  centralisation  of  procurement, 
especially  of  medical  equipment,  could  lead  to  lower  risks  of  corruption.  Currently, 
procurement of medical equipment is conducted at the local level. Due to a lack of checks 
and  balances  at  the  local  level,  much  corruption  occurs.  Although  centralising  the 

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procurement  of  medical  equipment  might  reduce  the  risk  of  corrupt  behaviour, 
stakeholders also indicated that its success would depend on who would be responsible for 
the central procurement. Not all central government bodies are seen as reliable bodies.  

EU-level interviews  

Representatives  from  MedTech  Europe  (speaking  in  their  personal  capacity),  AIM  and 
ASSPRO  (speaking  in  their  personal  capacity)  agreed  that  centralisation  of  procurement 
can  lower  corruption  risks.  However,  the  interviewees  added  a  general  note  that  any 
change in the status quo always brings risks with it as well. 

4.2.3.   Conclusion 3: Central procurement systems can become vulnerable as 

targets for lobbyists and more politically inspired types of corruption 

Survey results 

More  than  70%  of  the  survey  respondents  agree  that  central  procurement  systems  can 
become vulnerable to lobbyists. Around 10% (3 in total) were of the opinion that central 
procurement systems are not vulnerable at all. The remaining 20% answered that they did 
not know. Overall, 31 respondents answered the question. 

Table 4.4 Answers to statement #3 (n=31) 

Central procurement systems can become vulnerable as target for lobbyist and 
more political inspired types of corruption (n=31) 
Yes 
To some extent 
Not 
Do not know 

15 
7 
3 
6 

As shown in the Figure, in North West Europe only two-thirds of the respondents agreed 
with  the  conclusion  that  a  centralised  procurement  system  can  become  vulnerable  to 
lobbyists. In the Mediterranean and Eastern Europe, more than 70% of the respondents 
were of the opinion that centralised systems can become vulnerable. Also noteworthy is 
that none of the Eastern Europe respondents disagreed with this conclusion.  

The  outcomes  might  indicate  that  the  risks  on  lobbying  and  political  inspired  types  of 
corruption  are  perceived  to  be  higher  in  the  Mediterranean  and  Eastern  Europe  area 
compared to North West Europe. 

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Figure 4.5 Geographical spread conclusion #3 (n=31) 

The number of respondents in each group: n= 7 (group 1), n= 13 (group 2), n= 11 (group 3). 

Fact finding missions  

Greece: Greek stakeholders agreed that central procurement is vulnerable as a target for 
lobbyists, at least to some extent. One stakeholder indicated that it would be important to 
find  the  right  balance.  Central  procurement  is  more  favourable  than  decentralised 
procurement; nevertheless, appropriate measures should be adopted to ensure that the 
central procurement should remain free of political corruption. Still, it is difficult to establish 
the right system under the current Greek conditions, i.e. the economic downturn and the 
political unwillingness to fight corruption. 

Croatia:  Croatian  stakeholders  held  diverging  views  about  this 
issue:  patient 
representatives held that decentralised procurement is only to some extent vulnerable to 
lobbyists,  and  there  was  disagreement  between  the  Ministry  of  Justice  –  who  is  of  the 
opinion that central procurement can indeed become vulnerable, and the Ministry of Health 
– which holds the opposing view. 

Lithuania: The opinions of the Lithuanian stakeholders on this statement were divergent. 
As  mentioned  previously,  stakeholders  noted  that  both  centralised  and  decentralised 
procurement systems have inherent risks for corruption. Improper marketing, which may 
result from this risk, is observed in Lithuania, and recently initiatives and legislation for the 
healthcare sector were put in place to combat this form of corruption.  

Hungary: Hungarian stakeholders agreed that central procurement systems could become 
vulnerable to lobbyists and a higher level of (political) corruption.  

Poland:  Polish  stakeholders  held  different  opinions  regarding  this  statement.  Some 
stakeholders indicated that the current decentralised procurement is also prone to lobbyists 
and  more  political  inspired  types  of  corruption.  According  to  those  stakeholders, 
introducing a central procurement system will not solve this problem. Other stakeholders 
indicated that a centralised system might be vulnerable for lobbyists; however, centralised 
procurement  is  still  preferable  as  it  is  easier  to  protect  a  centralised  system  than  a 
decentralised system from lobbyists. 

Romania:  Romanian  stakeholders  agreed  with  this  statement.  One  of  the  problems 
mentioned is the central medication list. Only medication included on this centrally adopted 
list will be (partially) reimbursed by the National Health Insurance House (the sole payer 
in  the  Romanian  system).  Lobbyists  already  try  different  tactics  to  get  their  products 

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included  on  the  list,  even  when  it  is  known  that  their  products  are  not  effective.  The 
lobbyists also try to influence physicians to prescribe their medication, even for diseases 
other than for which it is indicated. 

EU-level interviews  

Representatives from AIM and ASSPRO agreed that centralisation of procurement can, to 
some extent, increase the risks of more political inspired corruption. 

4.2.4.  Conclusion 4: Bribery in medical service delivery cannot be contested 

with only targeted policies against the phenomenon as such, but need to 
be supplemented with accompanying (structural) measures 

Survey results  

As  stated  in  Section  4.1,  corruption  in  healthcare  is  not  an  isolated  phenomenon:  it  is 
correlated with corruption in society as a whole. It is therefore interesting to see that the 
question whether bribery in medical service delivery can be contested with only targeted 
policies is a topic of debate. As the answers to this survey question show, about 50% of 
the respondents (out of a total of 31) indicated that accompanying (structural) measures 
need to be taken to effectively combat bribery in medical services delivery. The other 50% 
indicated that they either disagree with this statement or did not know.  

This wide variety of answers given in the survey is line with the findings of the country 
missions, desk research and the previous study. 

Table 4.5 Answers to statement #4 (n=31) 

Bribery in medical service delivery cannot be contested with only targeted policies 
against the phenomenon as such , but need to be supplemented with accompanying 
(structural) measures (n=31) 
Yes 
To some extent 
Not 
Do not know 

7 
9 
6 
9 
Bribery in medical service delivery cannot be contested with only targeted policies against the phenomenon as 
such, but need to be supplemented with accompanying (structural) measures (n=31) 

The  differences  in  opinions  can  also  be  seen  when  analysing  the  results  per  region.  In 
North  West  Europe,  the  minority  had  the  opinion  that  besides  targeted  policies,  more 
structural changes are needed. However, it should be noted that bribery in medical services 
is less common in this region. In regions where bribery in medical service delivery is still 
common, the majority of the respondents (51%, or 72% excluding ‘don’t know’) agreed 
that both targeted policies and structural measures are required to fight this problem.  

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Figure 4.6 Geographical spread conclusion #4 (n=31) 

The number of respondents in each group: n= 7 (group 1), n= 13 (group 2), n= 11 (group 3). 

Fact finding missions  

Note: the fact-finding missions to Croatia, Hungary and Romania found that respondents 
in these three countries evaluated this statement almost identically. 

Interviewees  pointed  to  a  variation  of  accompanying  measures:  strengthening  of  the 
judicial system, changes in the healthcare system and changes in attitudes towards corrupt 
practices.  

Greece: All stakeholders interviewed fully agreed with conclusion #4. In order to make 
targeted policies effective, the interviewees indicated that the judicial system should also 
be strengthened. Enough capacity should be freed up to deal with cases of corruption and 
the people caught should be brought to justice and receive punishment. Only under these 
conditions,  targeted  policies  and  a  well-functioning  judicial  system,  can  corruption  be 
combatted. 

Croatia: All Croatian stakeholders, apart from the Ministry of Health, agreed that bribery 
in medical service delivery cannot be contested only with targeted policies against bribery, 
but have to be supplemented by accompanying (structural) measures. As in both Hungary 
and Romania, bribery in medical service delivery was and still is, to some extent, deeply 
embedded in the Croatian healthcare system and culture. The government has made an 
effort to make it clear to patients that paying the physician is unethical and undesirable. 
While  a  change  in  culture  may  still  take  years,  respondents  observed  that  younger 
generations are already less inclined to pay the physician for services received. 

Lithuania: One stakeholder fully agreed with this statement, one partially, and the others 
answered  ‘do  not  know’.  This  may  be  related  to  the  fact  that  the  effectiveness  of 
implementation of new measures and legislation has not been systematically evaluated. 

Hungary: Hungarian stakeholders agreed that bribery in medical service delivery cannot 
be solved solely by targeted measures against bribery, but need to be supplemented by 
accompanying (structural) measures. Like both Croatia and Romania, bribery in medical 
service delivery is deeply embedded in the Hungarian healthcare system and culture. The 
only  way  to  reduce  informal  payments  is  to  make  it  clear  to  patients  that  paying  the 
physician  is  unethical  and  undesirable.  While  a  change  in  culture  may  still  take  years, 
respondents  were  hopeful  as  younger  generations  are  already  less  inclined  to  pay  the 
physician for services received. 

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Poland:  Polish  stakeholders  agreed  that  bribery  in  medical  services  delivery  cannot  be 
solved solely by targeted measures. In order to successfully combat informal payments, 
the Polish government actively investigated and prosecuted physicians accused of bribery. 
Many of them were convicted and had to pay a fine. Several of them also lost their license. 
According  to  the  stakeholders,  the  convictions  were  effective  and  both  physicians  and 
patients  became  aware  of  the  undesired  effects  of  bribery.  As  a  result,  the  number  of 
informal payments has decreased strongly during the last few years. 

Romania:  Much  like  both  Croatia  and  Hungary,  bribery  in  medical  service  delivery  is 
deeply embedded in the Romanian healthcare system. Stakeholders indicated that paying 
the physician for medical services delivered is part of Romanian culture. The only way to 
reduce  informal  payments  is  to  make  it  clear  to  patients  that  paying  the  physician  is 
unethical and undesirable. Only a change in culture could tackle the problem of bribery in 
medical  service  delivery.  According  to  stakeholders,  this  could  still  take  years. 
Nevertheless, they are hopeful as younger generations are already less inclined to pay the 
physician for services received. 

EU-level interviews  

Representatives  from  AIM  and  ASSPRO  agreed  that  bribery  in  medical  service  delivery 
cannot be addressed only through targeted policies, but need accompanying (structural) 
measures. 

4.2.5.  Conclusion 5: Raising salaries does not have a significant preventive 

effect on reducing bribery in medical service delivery 

Survey results 

In the survey, the majority of the stakeholders (65% of the 31 respondents) indicated that 
raising  salaries,  at  least  to  some  extent,  does  not  have  a  significant  effect  on  reducing 
bribery in medical service delivery. Nevertheless, 23% of the respondents held the opinion 
that raising salaries will help to solve the problem with regard to bribery in medical service 
delivery. 

Table 4.6 Answers to statement #5 (n=31) 

Raising salaries do not have significant preventive effect on reducing bribery in 
medical service delivery (n=31) 
Yes 
To some extent 
Not 
Do not know 

10 
10 
7 
4 

Based on the geographical spread, as presented in the Figure below, respondents in the 
Mediterranean and Eastern Europe generally agreed with the conclusion of SHC1. These 
are  regions  where  bribery  in  medical  service  delivery  is  common  and  is  also  seen  as  a 
major problem. In North West Europe, the responses were more diverse, and this region 
had the relatively largest group of respondents that indicated raising salaries would help 
to solve the problem. However, it should be noted that bribery in medical service delivery 
is less common in this region. 

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Figure 4.7 Geographical spread conclusion #5 (n=31) 

The number of respondents in each group: n= 7 (group 1), n= 13 (group 2), n= 11 (group 3). 

Fact finding missions  

Greece: The opinions of the stakeholders consulted differ in regard to this conclusion. 
Some stakeholders indicated that raising salaries would help in reducing bribery in 
medical services delivery. Other stakeholders indicated that salaries should increase 
substantially, before they could have any effect. One stakeholder indicated that the 
salaries would have to be increased multiple times before some effect might be observed 
and suggested that other measures should be taken in order to combat bribery in 
medical service delivery.  

Croatia: Croatian stakeholders agreed that raising salaries does have a significant effect 
on preventing bribery, although it was stressed that this alone cannot solve the 
problems. 

Lithuania: Some Lithuanian stakeholders mentioned that raising salaries might have a 
preventative effect, whereas others are of the opinion that this effect would be (very) 
limited. One stakeholder mentioned that evidence from other countries shows that only 
raising salaries cannot solve the problem.  

Hungary: The Hungarian stakeholders we spoke with agreed that raising salaries is a 
necessary element of reducing bribery, but is not sufficient in itself, particularly because 
a small proportion of healthcare professionals only receive informal payments. 
Transparency International stressed that it may also lead to higher bribes. 

Poland: Stakeholders in Poland agreed that raising salaries cannot be successful as a 
standalone measure to prevent bribery in medical service delivery. The salaries of 
physicians, particularly specialists, have increased during the past few years. In addition 
to the rise in salaries, physicians that accepted bribes have also actively been 
prosecuted. The combination of the two instruments has reduced the number of informal 
payments made to physicians. In addition, awareness on the part of patients has 
increased as they became more aware of the unethical aspects of bribery. 

Romania: Salaries for physicians and other medical personal are extremely low in 
Romania. Stakeholders indicated that these low salaries are a trigger to accept bribes as 
it provides physicians and other medical staff with some additional income. Several 
stakeholders indicated that raising the salaries would persuade some physicians to stop 
accepting bribes. However, stakeholders also indicated that offering bribes (especially 

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gifts following medical services delivery) is very common, and this does not depend on 
the level of the salaries paid. It can therefore be concluded that raising salaries might 
provide incentives for physicians to refuse bribes (as there is no need to expand their 
income); however, it will not discourage the offering of bribes (as this is not influenced 
by the physician’s salaries, but has a more cultural aspect). 

EU-level interviews  

Representatives from AIM and ASSPRO held similar views on this statement, namely that 
raising salaries can at most only help to some extent. AIM stressed that although raising 
salaries may have some effect, it does not protect against misuse, and, in addition, many 
countries cannot afford it. 

4.2.6.   Conclusion 6: The root causes of corruption in healthcare are related to 

different factors 

Important  root  causes  of  corruption  are  (i)  ineffective  managerial  structures,  (ii) 
inappropriate financing mechanisms, (iii) insufficient health care capacity, (iv) insufficient 
funding for independent medical research, (v) unequal allocation of resources and (vi) a 
general acceptance of corruption in society. 

Survey results  

In  the  stakeholder  survey,  respondents  were  asked  which  root  causes  contribute  to 
corruption  in  the  health  care  sector.  29  respondents  answered  the  question.  As  can  be 
seen  in  the  Table  below,  the  most  frequently  mentioned  root  causes  were;  a  general 
acceptance  of  corruption  (23),  ineffective  managerial  structures  (22),  inappropriate 
financing mechanisms and unequal allocation of resources (both 20 times mentioned). 19 
respondents  mentioned  insufficient  health  care  capacity  and  17  respondents  mentioned 
insufficient funding for independent medical research. 

Table 4.7 Answers to statement #6 (n=29) 

The root causes of corruption in healthcare are related to: (n=29) 

Ineffective managerial structures 

Yes 
To some extent 
Not 
Do not know 

Yes 
To some extent 
Not 
Do not know 

Yes 
To some extent 
Not  
Do not know 

18 
4 
1 
6 

Inappropriate finance mechanism 

13 
7 
4 
5 

Insufficient healthcare capacity 

11 
8 
5 
5 

Insufficient funding for independent medical research 

Yes 
To some extent 
Not  
Do not know 

Yes 
To some extent 
No 
Do not know 

12 
5 
3 
9 

Unequal allocation of resources 

10 
10 
6 
3 

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A general acceptance of corruption in society 

Yes 
To some extent 
No  
Do not know 

14 
9 
1 
5 

The results per region are presented in the Figures below. 

Figure 4.8 Geographical spread conclusion #6 (Mediterranean) 

Figure 4.9 Geographical spread conclusion #6 (Eastern Europe) 

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Figure 4.10 Geographical spread conclusion #6 (North West Europe) 

Fact finding missions  

Greece:  The  Greek  system  has  to  deal  with  many  of  the  highlighted  root  causes. 
Stakeholders  indicated  that  the  current  managerial  structures  are  insufficient  (hospital 
managers  are  appointed  based  on  political  affiliation,  not  on  experience),  the  financing 
mechanisms  are  inappropriate  (there  is  only  one  general  budget,  resource  allocation  to 
specific hospitals is missing), the healthcare capacity is not efficient (there are too many 
physicians  which  increases  competition),  and  corruption  is  generally  accepted.  Several 
stakeholders indicated that ‘under the table’-payments are part of Greek culture and are 
therefore very difficult to erase.  

Croatia:  Croatian  stakeholders  were  most  in  agreement  about  unequal  allocation  of 
resources, inefficient managerial structures, and insufficient funding. Disagreement existed 
with  regard  to  the  role  of  ‘a  general  acceptance  of  corruption  in  society’,  which  the 
governmental  stakeholder  argued  is  an  important  cause,  but  is  not  one  according  to 
representatives of the Medical Chamber and pharmaceutical association. 

Lithuania: Stakeholders reported multiple root causes for corruption in Lithuania, of which 
the  most  commonly  mentioned,  and  most  important  according  to  the  stakeholders,  are 
ineffective managerial structures, the general acceptance of corruption in the society and 
the unequal allocation of resources.  

Hungary:  General  acceptance  of  corruption  in  society  was  mentioned  by  all  Hungarian 
stakeholders  who  provided  feedback  on  the  different  statements.  Insufficient healthcare 
capacity,  insufficient  funding,  inappropriate  financing  mechanisms  and  an  unequal 
allocation of resources were also highlighted as important, by the patient association and 
Transparency  International.  Ineffective  managerial  structures  were  also  deemed  an 
important  cause,  although  the  academic  respondent  stressed  that  causation  could  be 
reversed, and an ineffective managerial structure may also be a consequence of corruption. 

Poland: The root causes for corruption mentioned by the Polish stakeholders were mainly 
the general  acceptance  of  corruption  in  the  society,  insufficient  healthcare  capacity  (i.e. 
long waiting lists) and inappropriate financing mechanisms. The general public in Poland 
does not support corruption in the form of informal payments. Nevertheless, they accept 
other forms of corrupt behaviour, for example using both public and private insurance in 
order  to  receive  quicker  and  better  access  to  public  healthcare  facilities.  Furthermore, 
public  expenditure  on  healthcare  is  low,  which  enables  industry  and  healthcare 
professionals  to  be  involved  in  other  corrupt  activities  (e.g.  corruption  in  procurement 
processes, improper marketing and double practice). 

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Romania:  The  main  problem  in  the  Romanian  healthcare  system  is  the  deep 
embeddedness of corruption. All stakeholders indicated that it is seen as common practice 
to  pay  a  bribe  for  medical  services  delivery,  during  a  procurement  process  for  medical 
equipment, or to have drugs placed on the medicine list. Other causes for a high level of 
corruption  are  insufficient  managerial  structures  (hospitals  managers  are  physicians, 
without  managerial  experience),  a  lack  of  physicians  (many  of  the  Romania  physicians 
have moved abroad), unequal and unfair allocation of funding, and a lack of checks and 
balances in the system. The causes are multiple, which also creates difficulties when trying 
to combat the problem.  

EU-level interviews  

Both AIM and ASSPRO agreed that ‘ineffective managerial structures’ and ‘inappropriate 
financing mechanisms’ are root causes of corruption in healthcare. ASSPRO further listed 
‘a general acceptance of corruption in society’ as another root cause. AIM did not list this 
as a factor, and instead added ‘insufficient healthcare capacity’ as another additional root 
cause. 

4.2.7.  Conclusion 7: The introduction of transparent waiting lists has a positive 

effect on reducing healthcare bribery 

Survey results 

75% of the survey respondents (29 in total) agreed to the statement that the introduction 
of  transparent  waiting  lists,  at  least  to  some  extent,  would  have  a  positive  effect  on 
healthcare  bribery.  Only  two  respondents  indicated  that  they  did  not  agree,  while  five 
respondents answered ‘do not know’. 

Table 4.8 Answers to statement #7 (n=29) 

The introduction of transparent waiting lists has a positive effect on reducing 
healthcare bribery (n=29) 
Yes 
To some extent 
Not 
Do not know 

15 
7 
2 
5 

As can be seen in the Figure below, in all regions the majority of the stakeholders agreed 
that  transparent  waiting  lists  would  have,  at  least  to  some  extent,  a  positive  effect  on 
reducing healthcare bribery. Of the respondents from the Mediterranean area, 86% had 
the opinion that transparent waiting lists are a solution to the problem.  

Although 75% of the respondents from Eastern Europe believed that transparent waiting 
lists would have a positive impact on the problem, only 25% were fully convinced of this 
fact. The remaining 50% were more cautious and indicated that transparent waiting lists 
will only contribute to some extent.  

In North West Europe 70% of the respondents had the opinion that transparent waiting 
lists would have a positive effect. This region has the highest share of respondents doubting 
the effect of transparent waiting lists, or not knowing what the effect could be. 

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Figure 4.11 Geographical spread conclusion #7 (n=29) 

The number of respondents in each group: n= 7 (group 1), n= 12 (group 2), n= 10 (group 3). 

Fact finding missions  

Greece: All stakeholders agreed that introducing transparent waiting lists would have a 
positive  effect  on  healthcare  bribery.  Currently,  patients  use  their  private  insurance  to 
obtain easier access to public hospital services. This means that people who cannot afford 
private insurance and therefore solely depend on public healthcare services have a reduced 
access  to  public  healthcare.  The  creation  of  transparent  waiting  lists  would  enable  all 
patients  to  see  their  position  on  the  list.  Unexpected  jumps  in  position  could  be  an 
indication of bribery.  

Croatia:  All  Croatian  stakeholders  agreed  that  transparent  waiting  lists  would  have  a 
positive effect on reducing healthcare bribery. 

Lithuania: The majority of Lithuanian stakeholders believed that transparent waiting lists 
have the potential to reduce bribery in healthcare delivery.  

Hungary:  Hungarian  stakeholders  agreed  that  transparent  waiting  lists  could  have  a 
positive effect on reducing healthcare bribery, although it may also only indicate to patients 
when and where they should provide a bribe to get preferential access. 

Poland: In general, Polish stakeholders agreed that transparent waiting lists would be an 
effective tool to combat corruption in the healthcare system. However, recent attempts to 
introduce such lists have not been successful. Currently, it is possible for a patient to check 
general waiting lists before going to a hospital, e.g. how many weeks it will take before a 
certain surgery can take place. The patient is, however, not able to see his/her position on 
a specific list and therefore does not receive actual information. In addition, waiting lists 
are  infrequently  updated,  which  leads  to  outdated  information  being  provided  to  the 
patients.  

Romania: There is no clear link between waiting lists and bribery in the public sector, as 
bribes are typically given after treatment has taken place (‘gratitude payment’). Within the 
private sector, a clearer link between waiting lists and bribery can be seen. Patients that 
can afford private care go to private clinics and make sure that they are referred to public 
hospitals where the required treatment can be given. By paying twice, these patients are 
able to bypass the waiting lists. 

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EU-level interviews  

The AIM representatives strongly agreed that increasing transparency in waiting lists has 
a positive effect, whereas ASSPRO’s representative classified its effect as only helping ‘to 
some extent’.  

4.2.8.   Conclusion 8: Prescription of generics instead of branded pharmaceutical 

products has a positive effect on reducing healthcare bribery 

Survey results  

In the survey 62% of the respondents (out of 29 respondents in total), indicated that they 
are of the opinion that the prescription of generics instead of branded pharmaceuticals has, 
at  least  to  some  extent,  a  positive  effect  on  reducing  healthcare  bribery.  Nonetheless, 
almost 30% had the opinion that such a measure would not be effective in the fight against 
bribery in healthcare. 

Table 4.9 Answers to statement #8 (n=29) 

Prescription of generics instead of branded pharmaceutical products has a positive 
effect on reducing healthcare bribery (n=29) 
Yes 
To some extent 
Not 
Do not know 

11 
7 
8 
3 

As can be seen in the Figure below, two-thirds of the stakeholders living in Eastern Europe 
were of the opinion that prescribing generics helps to fight healthcare bribery. This result 
is in line with the findings of the fact-finding missions and the previous study, which also 
show  that  in  these  countries  several  policies  focus  on  the  mandatory  prescription  of 
generics instead of branded pharmaceuticals.  

In the other two regions, the views held by stakeholders are more or less similar. Around 
60% believe that this measure will, at least to some extent, contribute to the fight, while 
30% do not believe prescription of generics will help in combatting healthcare bribery. 

Figure 4.12 Geographical spread conclusion #8 (n=29) 

The number of respondents in each group: n= 7 (group 1), n= 12 (group 2), n= 10 (group 3). 

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Fact finding missions  

Greece: Some respondents indicated that this measure would have a positive effect, while 
others doubt it. They indicated that several attempts have already been made by the Greek 
government, but that the results have been minimal so far.  

Croatia: Most Croatian stakeholders argued that prescribing generic drugs does not have 
a positive effect on reducing healthcare bribery – indeed; it was argued they could lead to 
more  bribery  as  patients  prefer  to  have  the  branded  drug.  Only  representatives  of  the 
Ministry of Health argued it was beneficial. 

Lithuania:  It  was  noted  that  this  statement  is  not  applicable  to  Lithuania  because 
physicians  have  to  prescribe  the  active  substance  rather  than  a  specific  pharmaceutical 
product.  

Hungary: Hungarian stakeholders disagreed with the statement that generic drugs reduce 
healthcare bribery.  

Poland: In Poland, lists of generic medicines exist and physicians are obliged to prescribe 
patients generics instead of branded pharmaceutical products. Despite the existence of the 
list, several physicians still prescribe branded pharmaceuticals. As a result, it is difficult to 
keep prices for pharmaceuticals low. While the current list and policy on the prescription 
of generics is not working satisfactorily, most stakeholders indicated that the prescription 
of  generics  will  have  a  positive  effect  on  the  healthcare  system  and  public  healthcare 
expenditure.  

Romania:  Stakeholders  did  not  agree  with  this  statement.  In  Romania,  only  medicines 
included  on  the  national  list  of  medicines,  adopted  by  the  Ministry  of  Health  and  the 
National  House  of  Insurance,  are  (partially)  reimbursed.  Part  of  this  list  refers  only  to 
generics  and  active  substances.  Although  reimbursement  is  based  on  a  prescribed 
substance  and  not  on  a  particular  brand,  multiple  opportunities  are  found  for  bribery. 
According  to  some  stakeholders,  bribing  for  introducing  substances  onto  the  subsisted 
medicines list is one of the main forms of corruption. 

EU-level interviews  

The AIM and ASSPRO representatives both mentioned that the prescription of generics only 
reduces healthcare bribery to some extent – as long as there is a large amount of money 
involved, corruption risks will persist. 

4.2.9.  Conclusion 9: Self-regulation between the industry and healthcare 

providers is needed to fight corruption in healthcare 

Survey results 

75%  of  all  stakeholders  (29  in  total)  agreed  with  the  conclusion  that  self-regulation 
between  the  industry  and  healthcare  providers  is  needed  to  fight  corruption  in  the 
healthcare  sector.  Only  two  respondents  (7%)  believe  that  self-regulation  will  not 
contribute to the fight against corruption. The remaining 17% does not know whether or 
not this measure will help. 

Table 4.10 Answers to statement #9 (n=29) 

Self-regulation between the industry and healthcare providers is needed to fight 
corruption in healthcare (n=29) 
Yes 
To some extent 
Not 
Do not know 

14 
8 
2 
5 

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The  views  on  whether  self-regulation  will  have  a  positive  effect  on  the  fight  against 
corruption differed substantially between the three regions. In the Mediterranean area 71% 
of the respondents indicated that they fully believe that self-regulation is important.  

In North West Europe 90% of the respondents indicated that self-regulation would, at least 
to some extent, contribute to reducing corruption in health care. None of the respondents 
in this region indicated that self-regulation would not be beneficial.  

Respondents in Eastern Europe seem to be the most sceptical, as a total of 66% indicated 
that  self-regulation  is,  at  least  to  some  extent,  needed.  Of  all  the  respondents  giving  a 
clear ‘yes’ as an answer, the share of respondents in Eastern Europe is the lowest (33% 
compared to 50% in North West Europe and 71% in the Mediterranean). 

Figure 4.13 Geographical spread conclusion #9 (n=29) 

The number of respondents in each group: n= 7 (group 1), n= 12 (group 2), n= 10 (group 3). 

Fact finding missions  

Greece: Not all stakeholders agreed that self-regulation is needed in the fight against 
corruption. The ones that were of the opinion that self-regulation is important also 
indicated that incentives for cooperation are needed. Without incentives, they assume 
that self-regulation would not have the desired effect. 

Croatia: Croatian stakeholders were in agreement about the importance of self-
regulation between industry and healthcare providers.  

Lithuania: Most stakeholders agreed that self-regulation between the industry and 
healthcare providers is needed to fight corruption in healthcare. It was noted that when 
the initiatives between the industry and healthcare providers are embedded into 
legislation, this helps enforcement. For example, response rates of the healthcare 
professionals in the transparency register are likely to increase in that case. Although 
there is not yet self-regulation in place between industry and providers in Lithuania, the 
pharmaceutical sector and the medical societies are taking steps to work together, e.g. 
they are working on a joint white paper on interaction and collaboration which is 
expected to be published in the first quarter of 2017. 

Hungary: Hungarian stakeholders held that self-regulation can help, but is not sufficient 
by itself. 

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Poland: Polish stakeholders agreed that self-regulation between the industry and 
healthcare providers is needed to fight corruption. However, they also indicate that some 
aspects of the self-regulation should be included in Polish law as well, in order to be able 
to better enforce the behavioural rules. Currently, physicians can easily evade the self-
regulation rules as there is no legal obligation to comply with the ethical codes and 
transparency codes adopted by the industry. 

Romania: Stakeholders partially agreed to the above statement. However, most of them 
also indicated that currently no clear initiatives are taken to impose any form of self-
regulation. Corruption is deeply embedded in the Romanian healthcare system and no 
clear incentives exist to combat this phenomenon. 

EU-level interviews  

The representative from ASSPRO did not agree that self-regulation between players is 
needed to fight corruption. On the other hand, both MedTech Europe and AIM 
representatives stated that it is important. 

4.2.10. 

Conclusion 10: Self-regulation among players (such as within the 

pharmaceutical industry or among physicians) is needed to fight 
corruption in healthcare 

Survey results  

Two-thirds  of  the  total  number  of  stakeholders  agreed  with  the  conclusion  that  self-
regulation  among  players  is  needed  in  the  fight  against  healthcare  related  corruption. 
About 20% of the respondents said they did not know whether self-regulation is needed. 
Four respondents indicated that self-regulation among players is not required. 

Table 4.11 Answers to statement #10 (n=29) 

Self-regulation among players (such as the pharmaceutical industry or doctors) is 
needed to fight corruption in healthcare (n=29) 
Yes 
To some extent 
Not 
Do not know 

11 
8 
4 
6 

When  the  answers  given  to  this  question  are  analysed  in  relation  to  the  geographical 
regions where the respondents came from, the analysis presented above is more or less 
confirmed. In all three regions, around two-thirds of the respondents were of the opinion 
that self-regulation among players is necessary. The share of respondents indicating that 
self-regulation is not required to combat corruption is highest in North West Europe (20%). 
In the other two regions, this percentage is lower: 14% in the Mediterranean and 8% in 
Eastern Europe. 

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Figure 4.14 Geographical spread conclusion #10 (n=29) 

The number of respondents in each group: n= 7 (group 1), n= 12 (group 2), n= 10 (group 3). 

Fact finding missions  

Greece:  Not  all  stakeholders  agreed  that  self-regulation  is  needed  in  the  fight  against 
corruption. The ones that were of the opinion that self-regulation is important also indicate 
that  incentives  for  cooperation  are  needed.  Without  incentives,  they  assume  that  self-
regulation will not have the desired effect. 

Croatia: Croatian stakeholders were in agreement about the importance of self-regulation 
between industry and healthcare providers.  

Lithuania:  Lithuanian  stakeholders  agreed  that  self-regulation  within  for  example  the 
pharmaceutical  industry  or  among  physicians,  can help  to  combat  corruption. There  are 
already initiatives in place for the pharmaceutical companies, but not yet among physicians 
or between different groups of stakeholders.  

Hungary: As in Croatia, Hungarian stakeholders held that self-regulation can help, but is 
not sufficient in itself. 

Poland:  Polish  stakeholders  agreed  that  self-regulation  within  for  example  the 
pharmaceutical industry or among physicians, can help to combat corruption. Comparable 
to Lithuania, there are initiatives in place for pharmaceutical companies. 

Romania: Stakeholders partially agreed to this statement. However, most of them also 
indicated that currently no clear initiatives are taken to impose any form of self-regulation.  

EU-level interviews  

The  representative  from  ASSPRO  did  not  agree  that  self-regulation  among  players  is 
needed  to  fight  corruption.  On  the  other  hand,  both  MedTech  Europe  and  AIM 
representatives  stated  that  it  is  important.  The  representative  from  AIM  however  also 
noted that, to date, it has been impossible to reach consensus among payers on the need 
for self-regulation. 

No consensus on the need of self-regulation among payers - statutory health insurance 
Both within and across countries there is a lack of consensus on the need for corporate compliance in statutory 
health insurance. Views on the matter differ substantially, ranging from the zero-tolerance principle to the 
acceptance of some form(s) of misuse because of other interests (e.g. ensuring a contract with a specific 

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provider).  These  different  interests  are  problematic  –  there  are  incentives  to  move  in  opposite  directions, 
and this makes it impossible to have a voluntary code of conduct amongst payers. 

4.2.11. 

Conclusion 11: Awareness raising campaigns and fraud and 

corruption reporting hotlines are an effective instrument to fight 
corruption in healthcare 

Survey results  

The majority of the stakeholders responded positively to the question. As can be seen in 
the Table below, more than 80% (24 out of the 29 respondents) indicated that they were 
of  the  opinion  that  campaigns  and  hotlines  are,  at  least  to  some  extent,  effective 
instruments.  Only two respondents  indicated that  they  did  not  agree  that  the  measures 
are effective, while three respondents answered that they did not know. 

Table 4.12 Answers to statement #11 (n=29) 

Awareness raising campaigns as well as fraud and corruption reporting hotlines are 
effective instruments to fight corruption in healthcare (n=29) 
Yes 
To some extent 
Not 
Do not know 

18 
6 
2 
3 

In all three regions, the majority of the respondents agreed with the SHC1 conclusion that 
awareness  campaigns  and  reporting  hotlines  are  effective.  In  North  West  Europe,  all 
respondents had a clear opinion, while in the other two regions several stakeholders were 
not able to answer the question. 

Figure 4.15 Geographical spread conclusion #11 (n=29) 

The number of respondents in each group: n= 7 (group 1), n= 12 (group 2), n= 10 (group 3). 

Fact finding missions  

Greece:  Although  all  stakeholders  agreed  that  awareness  campaigns  are  needed  in 
combatting  corruption,  some  stakeholders  indicated  that  campaigns  are  not  the  best 
measure. 

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Croatia:  Croatian  stakeholders  agreed  that  awareness  raising  campaigns  and  reporting 
hotlines can be an effective additional instrument to fight corruption. However, it was noted 
that citizens often do not report corruption, and the Ministry of Justice stressed the citizens 
would not usually use hotlines for this purpose. 

Lithuania:  Lithuanian  stakeholders  agreed  that  awareness  raising  campaigns  and 
reporting  hotlines  are  important  instruments  to  fight  corruption.  Lithuania  recently 
introduced  various  awareness  raising  campaigns  and  set  up  two  hotlines.  These  are 
perceived to be effective instruments by several stakeholders.  

Hungary: Hungarian stakeholders held the opinion that awareness raising campaigns and 
hotlines  are  an  important  instrument,  but  cannot  be  effective  in  reducing  corruption  by 
themselves. 

Poland:  Several  stakeholders  actually  started  awareness  raising  campaigns  and  they 
indicated  that  their  own  instruments  were  effective.  It  should  be  noted  that  these 
instruments are strongly internally focussed and do not involve the general public. As a 
result, within public administrations and industry associations, awareness campaigns are 
seen as valuable instruments, but it is doubtful whether the Polish citizens are aware of all 
actions  taken.  Also,  the  perception  of  the  patients  regarding  what  constitutes  corrupt 
behaviour is rather unclear. Corrupt practices regarding privileged access, for instance, are 
seen as perfectly normal. 

Romania:  Stakeholders  partially  agreed  with  the  statement.  Although  they  were  of  the 
opinion  that  awareness  campaigns  and  hotlines  are  important,  they  also  remarked  that 
results of such initiatives are limited. The government, especially the Integrity Department 
of the Ministry of Health, introduced several initiatives for the public to report on corruption. 
An example of this is a website where patients can report on bribes paid, bad care received 
and other malpractices. However, the number of complaints and reports received is low. It 
seems that patients are not willing to share their experiences with governmental agencies.  

EU-level interviews  

The ASSPRO representative noted that awareness raising campaigns and hotlines help to 
some  extent  in  fighting  corruption.  AIM  representatives  attached  greater  significance  to 
the positive effect of these instruments. 

4.2.12. 

Conclusion 12: The government should play a (more) active role in 

creating transparency in the relations between the industry and 
healthcare providers 

Survey results  

24 out of the 29 stakeholders (equalling 82%) indicated that the government should play 
a role in creating transparency in the relations between industry and healthcare providers. 
Three  respondents  (10%)  indicated  that  there  is  no  desire  for  a  larger  role  for  the 
government, while the two remaining stakeholders answered that they did not know. 

Table 4.13 Answers to statement #12 (n=29) 

The government should play a (more) active role in creating transparency in the 
relations between the industry and healthcare providers (n=29) 
Yes 
To some extent 
Not 
Do not know 

21 
3 
3 
2 

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As can be seen in the Figure below, the perception about the role the government could 
play in increasing transparency differs between the regions:  

 

 

 

In the Mediterranean region, 71% indicated that the government should play a 
role.  
In Eastern Europe, 84% indicated that the government could, at least to some 
extent,  play  a  role.  67%  indicated  that  they  see  a  clear  role,  while  the  other 
17% see some role for the government.  
In North West Europe, 90% of the respondents see a role for the government. 
80% see a clear role, while 10% see some role.  

Overall, one can conclude that the respondents in North West Europe are the most positive 
about the role the government could play in increasing transparency between industry and 
healthcare providers. 

Figure 4.16 Geographical spread conclusion #12 (n=29) 

The number of respondents in each group: n= 7 (group 1), n= 12 (group 2), n= 10 (group 3). 

Fact finding missions  

Greece: All Greek stakeholders indicated that the government should play an active role 
in creating more transparency in the relations between industry and healthcare providers. 
However, the current Greek laws still allow for certain favours, e.g. direct sponsorship is a 
valid activity. This will make it more difficult to create more transparency. Whether or not 
a political willingness exists to increase transparency is unknown.  

Croatia: Croatian stakeholders were divided with regard to this statement: whereas the 
Croatian Medical  Chamber  argued that  the  government  had no  role, the pharmaceutical 
association argued it could be helpful if the government put this issue on the agenda. The 
patient organisation argued that a governmental role is more necessary for physicians, as 
the industry has already introduced self-regulation. The Ministry of Health and Justice both 
saw a role for government to create more transparency.  

Lithuania: All stakeholders agreed that the government should play a (more) active role 
in creating transparency in the relations between the industry and healthcare providers. 
Initiatives  for  increasing  transparency  have  been  introduced,  and  the  Ministry  of  Health 
would like to take a more active role in this, for example by exploring the possibilities for 
embedding  initiatives  in  the  sector  into  law.  A  working  group  has  been  set-up  for  this 
purpose.  

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Hungary:  Hungarian  stakeholders  were  split  about  the  role  government  should  play  in 
creating transparency. Whereas the academic respondent and Transparency International 
argued that the government should step up to the plate, the patient association was wary 
of a greater government role.  

Poland: The Polish stakeholders partially agreed with the statement. Several stakeholders 
would like to see the government playing a bigger role in creating transparency. However, 
currently  no  initiatives  are  taken  that  focus  on  creating  more  transparency  in  the 
healthcare sector. The transparency-related measures taken thus far focus on the internal 
processes of the government. 

Romania:  Although  stakeholders  agreed  with  the  statement,  most  of  them  are  also 
sceptical about the role of the government. Several signals were received that the newly 
elected  government  (in  place  since  mid-December  2016),  is  particularly  unwilling  to 
actively combat corruption. A good example is the recent proposal for a law to decriminalise 
all corruption cases of less than EUR 45,000. As a result, these would count as non-corrupt 
payments.  

EU-level interviews  

The representative from AIM stated that the government should only have an active role 
in  increasing  transparency  to  some  extent,  because  it  might  lead  others  to  ‘game’  the 
regulations  and  self-regulation  is  a  necessary  element  as  well.  ASSPRO  representatives 
stated that the government should have an active role without reservations. 

4.2.13. 

Conclusion 13: Active – independent – media involvement and 
pressure from ‘civil society’ watchdogs are essential to fight corruption in 
healthcare. 

Survey results  

The importance of active media involvement and pressure from civil society watchdogs was 
seen  as  at  least  to  some  extent  relevant  by  82%  of  the  survey  respondents.  Two 
respondents  indicated  they  did  not  see  a  role  for  media  and  watchdogs,  while  three 
respondents answered that they did not know. 

Table 4.14 Answers to statement #13 (n=29) 

The importance of active – independent – media involvement and pressure form 
‘civil society’ watchdogs is essential to fight corruption in healthcare (n=29) 
Yes 
To some extent 
Not 
Do not know 

18 
6 
2 
3 

Based on the geographical distinction, one can observe that 75% of respondents in Eastern 
Europe are of the opinion that the involvement of media and watchdogs is, at least to some 
extent,  essential  to  fight  corruption.  In  the  Mediterranean  region  this  is  85%  of  the 
respondents, while in North West Europe it is 90%. 

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Figure 4.17 Geographical spread conclusion #13 (n=29) 

The number of respondents in each group: n= 7 (group 1), n= 12 (group 2), n= 10 (group 3). 

Fact finding missions  
Greece: All stakeholders agreed, at least to some extent, that more media involvement 
and  civil  pressure  are  needed.  However,  stakeholders  also  indicated  that  civil  society 
watchdogs  are  hardly  present.  For  example,  Transparency  International  Greece  is  not 
active in the field of healthcare corruption. Also, websites where cases of corruption can 
be reported are rarely used. There is still a long way to go, according to some stakeholders.  

Croatia:  Whereas  all  Croatian  stakeholders  we  spoke  with  agreed  that  active  and 
independent  media  involvement  is  important,  the  Medical  Chamber  and  pharmaceutical 
association  had  concerns  regarding  the  independence  and  partisanship  of  the  Croatian 
media. 

Lithuania:  The  Lithuanian  stakeholders  all  agreed  that  active  and  independent  media 
involvement is important. One example in this context is the active role of Transparency 
International in Lithuania, where they are playing an important role in creating awareness 
(both  with  regard  to  best  practice  and  recent  cases)  and  enabling  discussions  between 
different actors in the healthcare sector on these topics through social design.  

In 2016, TI Lithuania conducted a research study in Lazdynai Outpatient Clinic using social design methods. 
In this research, they changed the environment of the clinic and tried to understand how and whether such 
change indirectly affects the behaviour of patients, physicians and other staff; and how it can influence their 
attitude towards the clinic, increase transparency and reduce bribery. 

The results of the research show that:  
- The initiatives helped to improve the patient-physician relationship.  
- Patients, who believe that gifts and informal payments do not help to get better services, were more likely 
to recommend the clinic to others. Thus, corruption perception levels can be directly related to the willingness 
to recommend the institution to others. 
- Patients, who took part in the Vitamin Lab, evaluated the clinic better and were less likely to think that 
informal gifts or material rewards could help them receive better services in that clinic 
- Patients who took part in the Vitamin Lab were more likely to recommend the clinic to others. 
For more information, see https://www.youtube.com/watch?v=G31HLtVdqyo. 

Hungary: Hungarian stakeholders agreed that active, independent media involvement and 
civil society watchdogs are essential to fight corruption in healthcare. 

Poland: Polish stakeholders agreed that active – independent – media involvement and 
pressure from ‘civil society’ watchdogs is essential to fight corruption in healthcare. At the 

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same time, stakeholders indicated that not many initiatives have been taken. An initiative 
that was started around 2002 was stopped several years ago as it was not perceived to be 
valuable, even by physicians who are openly against bribery. 

Romania: All stakeholders fully agreed that investigative journalism is important in the 
discussions about corruption. Since 2013, discussing corruption in the healthcare system 
has become more common, and the public is speaking up against the current bad practices. 
Several stakeholders indicated that investigative journalism is an important factor in the 
discussion about  combatting  corruption.  The journalists  fuel  the  current  discussions  and 
contribute to the non-acceptance of corruption in all Romanian sectors. 

EU-level interviews  

Representatives  from  both  AIM  and  ASSPRO  indicated  that  active  independent  media 
involvement and pressure from civil society watchdogs is essential to fighting corruption in 
healthcare. 

4.3.  Thematic deepening 
This section describes and analyses the developments in relation to the thematic areas of 
focus for this study, namely: 

  Privileged access to medical services (including informal payments and the use 

 

of privileged information and information peddling);  
Improper  marketing  by  pharmaceutical  companies  and  medical  device 
producers (at national and/or EU level, including for market authorisation and 
reimbursement approval); 

  Potential risks involving double practice in public and private clinics.  

4.3.1.  Theme 1: Privileged access 
Closer analysis of the Special Eurobarometer 397 on corruption in healthcare perceptions 
reveals  that  the  perceptions  may  be  influenced  by  general  perceptions  of  corruption  in 
society, but also by one specific type of corruption in healthcare: bribery in medical service 
delivery.  A  conclusion  from  Figure  4.18  may  be  that  there  is  a  correlation  between 
perceptions of corruption in healthcare and experiences in actually giving fees, an extra 
payment or a valuable gift to a nurse or a physician, or a donation to the hospital. However, 
corruption  in  the  healthcare  sector  may  cover  more  types  of  corruption  than  bribery  in 
medical service delivery. 

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Figure 4.18 Correlation between perceptions of corruption in healthcare and experiences 
with bribery in medical service delivery 

Source: Ecorys 2016, derived from Special Eurobarometer 397, 2014 (fieldwork February - March 2013), Table 
QB7 and QB2 (yes + refusal). 

The  Special  Eurobarometer  provides  more  detail  on  different  ways  that  the  situation  of 
giving an extra payment, gift or hospital donation may have arisen. Patients may have felt 
that they had to give an extra payment or valuable gift and did so before and / or after 
care  was  given.  They  may  also  have  been  requested  to  provide  an  extra  payment  or 
valuable  gift  in  advance  and  /  or  following  the  treatment.  Countries  that  score  high  on 
general corruption (in healthcare) perceptions generally score high on these sub-indicators. 

Survey results  

A total of 28 respondents answered the question regarding whether or not privileged access 
to  medical  services  occurs  frequently  in  their  country.  25%  (7  respondents  in  total) 
indicated that privileged access does happen often or all the time. 43% (12 respondents 
in  total)  indicated  that  privileged  access  does  happen  sometimes  or  occasionally.  Two 
respondents (equalling 7%) indicate privileged access never happens. The remaining seven 
respondents did not know the answer. 

Table 4.15 Answers given to statement on privileged access (n=28) 

Does privileged access to medical services frequently occur in your country? 
(n=28) 
5 All the time  
4 Often  
3 Sometimes 
2 Occasionally 
1 Never 
- Do not know 

Total 

4 
3 
5 
7 
2 
7 

In the Figure below, the geographical spread of the answers for each of the three defined 
regions is presented. As can be seen, in the Mediterranean region privileged access seems 
the most common, as 57% of the respondents indicated that privileged access happens all 

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the  time,  compared  to  8%  in  Eastern  Europe  (often)  and  22%  in  North  West  Europe 
(often).  

Also  interesting  to  note  is  that  Eastern  Europe  is  the  only  region  where  some  of  the 
respondents indicated that privileged access never happens. It is not clear why this should 
be the case. 

Figure 4.19 Geographical spread for privileged access (n=28) 

The number of respondents in each group: n= 7 (group 1), n= 12 (group 2), n= 9 (group 3). 

In response to the question regarding whether or not the respondent is aware of specific 
policies and practices aimed at preventing and controlling privileged access, 39% indicated 
that they were aware of specific policies, while the remaining 61% indicated that they were 
not familiar with any such policies. 

Table 4.16 Answers to the question regarding awareness of specific policies and 
practices to prevent and control privileged access 

Are you aware of specific policies and practices to prevent and control privileged 
access to medical services in your country? (n=28) 
Yes 
No 

Total 

11 
17 

Fact finding missions  

In Greece the topic of privileged access is closely linked to double practice. Patients mainly 
use the availability of double practice to obtain privileged access to public hospitals. The 
patient first visits the physician in his/her private clinic and pays the physician with both 
private  insurance  as  well  as  under-the-table  payments  (i.e.  double  payment).  Once  the 
physician is paid, the patient is admitted directly to the public hospital and he/she is placed 
higher on the waiting list. By visiting the physician in a private clinic, waiting lists in public 
hospitals are bypassed.  

In Croatia, gifts to physicians are becoming less common but still exist to some extent. 
The  culture  is,  however,  changing,  in  part  because  attention  is  now  paid  to  the  risk  of 

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corruption during medical education. In addition, it is now regulated through the Conflict 
of Interest Act. This cultural change has taken place in society over the last 15 years. 

In Lithuania the healthcare sector is very informal and it is generally accepted by society 
to pay small bribes to physicians in the form of gifts or money, either to gain access or to 
show gratitude. The mind-set is changing however, with the shift in generations; younger 
physicians and patients do not necessarily consider it common practice. Not only informal 
payments,  but  also  informal  relations  can  play  an  important  role  in  gaining  access  to 
treatment or to a physician. This holds for all types of healthcare; from family doctor visits 
to tertiary hospital services. The importance of informal relations creates risks for unequal, 
and privileged, access to healthcare. 

In Hungary, informal payments are ubiquitous. A law prohibits informal payments before 
treatment, but they are allowed when given after treatment has taken place. There is a 
separate clause in the labour law prohibiting ‘gratitude’ payments, but this can be (legally) 
overruled  by  the  director  of  a  hospital,  whose  formal  approval  removes  the  prohibition. 
The distribution of informal payments is very skewed as it is mostly the head physicians 
who  receive  these  payments.  About  60%  of  all  informal  payments  go  to  5%  of  all 
physicians. The younger generation receives less informal payments, and is also less willing 
to rely on them. As a consequence, younger healthcare professionals often go work abroad. 
This is particularly relevant for nurses, whose wages are low and who do not benefit from 
the informal payments at all. 

Privileged access is a serious problem in Poland. In this country the waiting lists are long, 
and it is often not clear to patients what their position is on a waiting list. In addition, most 
employed  Poles  are  both  publicly  and  privately  insured.  In  order  to  move  to  a  higher 
position  on  the  waiting  list,  the  patient  first  goes  to  a  private  hospital.  Here,  he  or  she 
receives  a  first  consultation  and  makes  sure  that  a  referral  to  the  public  hospital  is 
provided.  Patients  who  follow  this  route,  are placed  higher  on  the waiting  lists  of  public 
hospitals. As a consequence, they are able to bypass fellow patients who are not following 
the  private  healthcare  route.  Patients  using  their  double  insurance  facilities  obtain 
privileged access over patients that cannot or will not follow this route. Most stakeholders 
confirmed that this is common practice in Poland.  

Examples exist in Romania where patients use their private insurance to obtain preferred 
access to a public hospital. Often a patient visits a physician in a private clinic and pays 
him or her an additional fee to get earlier access to treatment, e.g. surgery, in a public 
hospital. As a result, patients that are not able to afford private care are confronted with 
longer waiting times, and face the risk of being excluded from the healthcare system.  

In addition to these findings, two initiatives in other EU countries are worth mentioning: 

New anti-corruption in healthcare law in Germany 
In April 2016, a new anti-corruption in healthcare law was adopted in Germany. One of the elements in this 
law, which is called “the fight against fraud and corruption in the healthcare sector”, concerns the prosecution 
of independent physicians. Before the new law came into force, independent working physicians could not be 
punished for bribery or corruption as a result of a verdict of the High Court. Since April 2016, these physicians 
can  be  prosecuted  and  punished  for  corruption.  Another  element  of  the  new  law  concerns  an  increased 
reporting obligation for notified bodies, such as the health insurance organisations. 

Privileged access and informal payments in Bulgaria 
According to the Bulgarian patients’ organisation, young physicians are pressured by older physicians to ask 
patients for informal payments. This is widespread in Bulgaria. Politicians and their relatives are not subject 
to pressures for informal payments as they have privileged access to the governmental hospital, which has 
the best equipment and is funded with public money. Physicians themselves are also sometimes driven to 
make informal payments to get access to a specialisation track for further education, or to ensure that they 
pass exams. The latter appears to happen primarily with foreign medical students, and may have deleterious 
effects on the quality of healthcare professionals. 

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EU-level interviews 

DG SANTE noted that waiting lists themselves may create the conditions for the 
imposition of bribes to help certain patients to circumvent the waiting lists or to be 
placed higher on the list. In general there are no comparable data available, which 
complicates transparency with regard to access to health care. DG SANTE further noted 
that Commission recommendations in the field of curbing informal payments focus on 
four countries: Latvia, Hungary, Bulgaria, and Romania. In the case of Romania, the 
European Commission is also directly working together with the national government to 
monitor the developments with regard to informal payments. 

The European Hospital and Healthcare Federation (HOPE) noted that a shift in types of 
corruption happened when 10 new Member States acceded to the European Union in 
2004. At that time, most of the attention was directed to informal payments. This 
amounted to a big culture shift compared to what the patient federation was used to in 
terms of their experiences in Western Europe. Nowadays, the focus is more on corruption 
in the general sense: influence of pharmaceutical companies, public procurement, etc. 

Transparency International stated its position that societies cannot accept out of pocket 
(informal) payments by patients for (access to) healthcare. Governments need to be in a 
position to properly pay for service delivery, much like is the case for education or other 
social services. 

4.3.2.  Theme 2: Improper marketing  
The special Eurobarometer does not give any information on the occurrence of improper 
marketing by pharmaceutical companies and medical device producers.  

In several countries, this topic is researched at the Member State level. For example, in 
the Netherlands, a study on the effect of sponsoring by pharmaceutical companies on the 
prescription behaviour of physicians was recently picked up by the media.  

Study on the effect of sponsoring by pharmaceutical companies on the prescription 
behaviour of physicians in the Netherlands 

On  22  December  2016,  the  Dutch 

newspaper  Volkskrant  published  an 

article entitled “Physicians more often 

choose 

drugs 

from 

sponsoring 

pharmaceutical 

companies”. 

The 

article outlines the results of a study 

that was conducted by the newspaper 

in cooperation with a health insurance 

company.  The  study  looked  into  the 

prescribing  behaviour  of  medical 

specialists for four new and expensive 

drugs, 

and 

sponsoring 

by 

pharmaceutical 

companies. 

The 

results show a statistically significant 

relationship between sponsoring and prescription behaviour but, as the article also notes, this 

is not hard evidence for improper influencing by the industry; there may be other factors in play 

that were not included in the study (e.g. differences in case mix between specialists). The results 

indicate that further research into this topic is warranted.  

In the context of improper marketing it is also important to consider the risks associated 
with lobbying. While lobbying is not necessarily a bad thing, it may create risks if conducted 
improperly.  In  2015,  Transparency  International  published  a  report  about  lobbying 

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practices in 19 countries and three EU institutions. The results show that in only seven out 
of  the  19  countries  in  the  study  there  is  dedicated  lobbying  regulation.  In  addition,  the 
study reveals that 58% of EU citizens believe that “their country’s government is to a large 
extent or entirely controlled by a few big interests”. Some of the other key findings of the 
study are that, in Europe131:  

  The lobbying landscape is diverse and (increasingly) complex;  
  Hidden and informal influences persist;  
  Lobbying regulation seems to be inadequate, despite the risk factors – the average 
score on the quality of the lobbying regulation is 31%. The average scores on the 
three dimensions of a comprehensive lobbying regulation system are:  

-  26% on transparency;  
-  33% on integrity; 
-  33% on equality of access.  

Survey results 

In the survey, stakeholders were asked if improper marketing often occurs in their country. 
Four respondents (equalling 15%) indicated that improper marketing happens often or all 
the  time.  11  respondents  (equalling  42%)  indicated  that  improper  marketing  happens 
occasionally or sometimes. Only one respondent indicated that improper marketing does 
not occur. It should be noticed that 10 respondents (38%) were not able to answer this 
question.  

Table 4.17 

Answers given to statement on improper marketing (n=26) 

Does improper marketing frequently occur in your country? (n=26)  Total 
5 All the time  
4 Often  
3 Sometimes 
2 Occasionally 
1 Never 
- Do not know 

3 
1 
4 
7 
1 
10 

As illustrated in the Figure below, none of the respondents in Eastern Europe indicated that 
improper marketing occurs often or all the time, while in the other two regions, the answers 
are more a less equal (i.e. 29% in the Mediterranean region compared to 26% in North 
West  Europe).  Eastern  Europe  is  also  the  only  region  where  stakeholders  indicated  that 
improper marketing does not happen.  

131 Transparency International (2015). Lobbying in Europe. Hidden Influence, Privileged Access. 
https://www.transparency.org/whatwedo/publication/lobbying_in_europe, page 7.  

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Figure 4.20 Geographical spread for improper marketing (n=26) 

The number of respondents in each group: n= 7 (group 1), n= 11 (group 2), n= 8 (group 3). 

To the question asking whether or not the respondent is aware of specific policies and 
practices aimed at preventing and controlling improper marketing, 46% indicated that 
they were aware of specific policies, while the remaining 54% indicated that they were 
not familiar with any such policy.  

Table 4.18 
practices to prevent and control improper marketing 

Answers  to  the  question  regarding  awareness  of  specific  policies  and 

Are you aware of specific policies and practices to prevent and control improper 
marketing in your country? (n=26) 
Yes 
No  

Total 

12 
14 

Fact finding missions  

Direct  sponsorship  is  allowed  under  Greek  law.  Many  medical  equipment  providers  are 
willing  to  pay  a  physician  in  order  to  ensure sales  of  their  products.  Physicians are  also 
keen to accept additional payments or other extras from providers, as it enables them to 
increase their income, which is rather low. Several of the larger multinational companies 
(which are members of MedTech Europe) have already adopted the new MedTech Code – 
which phases out direct sponsorship - and will likely also apply this to their distributors. In 
addition,  SEIV  (the  national  trade  association  for  medical  equipment  and  devices 
companies)  has  already  translated  the  newly  adopted  MedTech  Code  and  in  June  2017, 
during the General Assembly, SEIV members will be asked to adopt the Greek translation. 
However, even when all SEIV members have adopted the Code, only a small proportion of 
the market will be bound by it, as many, particularly smaller, companies are not members 
of the SEIV. This may create problems in the implementation of the Code, and particularly 
the phasing out of direct sponsorship.  

In  Lithuania  several  measures  were  introduced  to  regulate  improper  marketing.  For 
example,  in  2014,  the Ministry  of Health  introduced  a  ban  on  gifts  from  pharmaceutical 
sales  representatives  to  physicians,  for  things  that  are  not  related  to  the  professional 

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activities of the physician. In addition, the pharmaceutical industry associations IFPA and 
VGA jointly introduced the Disclosure Code, according to which pharmaceutical companies 
have to disclose their payments for scientific events to physicians. The code is followed by 
40  companies,  and  the  industry  associations  estimate  that  the  percentage  of  personal 
disclosure is 75%. While the Disclosure Code is currently a self-regulation measure, the 
Ministry  of Health  is  looking  into the  possibility  of  introducing  legislation  on this.  This  is 
encouraged  by  the  pharmaceutical  sector  in  Lithuania.  With  regard  to  lobbying,  on 
December  9th  2016,  the  new  Minister  of  Health  talked  in  his  speech  about  the  issue  of 
illegal lobbying practices. Currently there is a lack of relevant legislation in this area, which 
creates risks for corrupt behaviour. The Ministry of Health is aware that there is still a lot 
of work to be done on this topic.  

Improper marketing, and in particular sponsorship of healthcare professionals, is a topic 
of debate in Poland. Both the pharmaceutical industry and medical equipment providers 
aim  to  reduce  (direct)  sponsorship.  The  relevant  associations  have  adopted  codes  of 
conduct, which aim to regulate which costs can and cannot be reimbursed when inviting 
physicians to conferences and other events. Such codes of conducts rely on self-regulation 
and  are  not  compulsory  by  law.  In  addition  to  the  codes  adopted  by  the  industry, 
governmental  organisations,  e.g.  the  Ministry  of  Health  and  NFZ  (the  sole  payer),  also 
have  codes  of  ethics,  which  indicate  under  which  circumstances  costs  incurred  by  civil 
servants can be reimbursed by the industry. The stakeholders interviewed indicated that 
such codes are effective and provide useful guidance to combat improper marketing.  

In Romania, examples of improper marketing were encountered in the relation between 
physicians  and  the  pharmaceutical  industry.  Once  a  pharmaceutical  company  has  its 
medicine included on the list of the Ministry, the company tends to approach physicians 
and offer them additional payments if they prescribe the listed medication. Examples were 
mentioned where physicians prescribe medication for diseases for which the medication is 
not intended, in order to increase their income.  

During the fact-finding missions to Croatia and Hungary the EFPIA Code of Conduct (see 
below)  was  referenced  multiple  times.  However,  no  additional  relevant  information 
regarding this theme was collected.  

EU-level interviews 

An  important  development  since  the  last  study  is  the  merger  of  Eucomed,  EDMA  and 
MedTech Europe at the end of 2016. This merger resulted in the trade association MedTech 
Europe, which represents the entire industry from diagnosis to cure. Before the merger (in 
2014),  MedTech  Europe  decided  that  one  of  the  first  things  they  needed  was  a  new 
common code of conduct that contains stringent rules on how industry should interact with 
healthcare  professionals  and  healthcare  organisations.  This  code  came  into  effect  on  1 
January 2017, outlining a new approach to the funding of healthcare professionals and the 
research community (academics).132 If implemented, it effectively puts a stop to the direct 
funding of individuals. The guideline has been adopted by the vast majority of MedTech 
members and represents a significant change in conduct.  

The code has a double monitoring system. On the one hand, MedTech Europe is monitoring 
what their members are doing and has given them until end of this year to phase out direct 
sponsorship. The reason for giving them time to achieve this is that in some countries it is 
not evident. On the other hand, MedTech Europe set up an independent compliance panel 
at the European level. Patients, physicians, and also competitors, can complain about an 
alleged infringement at this panel. It is expected that particularly the (potential) complaints 
by competitors will regulate the industry. If the assessment of the panel shows that there 

132 This presentation can be found here: http://www.medtecheurope.org/industry-themes/topic/122.  

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is  an  infringement,  there  is  a  list  of  sanctions  that  the  panel  can  choose  to  impose  on 
member companies. 

Several other initiatives found through desk research are also worth mentioning:133  

EFPIA self-regulation 
The  European  Federation  of  Pharmaceutical  Industries  and  Associations  (EFPIA)  is  the  overarching 
association of national pharma industry associations. It has several self-regulation initiatives, such as 
the HCP Code and the PO Code. Recently, it adopted a ‘Disclosure Code’ to supplement these two. The 
latest self-regulation initiative demands that its members disclose, on their websites, the transfers of 
value  given  to  healthcare  professionals  and  healthcare  officers134  Its  stated  aim  is  to  ‘secure  the 
integrity  of  the  decision  and  encourage  a  consistent  disclosure  approach’.  It  is  applicable  to  all  EU 
member states as well as Switzerland, Turkey, Norway, Russia, Serbia and Ukraine; enforcement of the 
Codes is discharged by the member associations. 

Self-regulation in Germany 
In  Germany,  there  is  an  interesting  development  where  self-regulation  has  turned  into  regulation. 
Healthcare professionals are no longer allowed to receive kickbacks when referring patients from the GP 
to the hospital. It was acknowledged that this is a problem, even at the Parliamentary level, where many 
physicians are represented. The legislation was also approved by them, which shows that the culture 
and perception in Germany has changed over the past few years. The new law, which added a criminal 
offence to Sec. 299a and Sec. 299b of the Criminal Code (“Strafgesetzbuch” – StGB) came into force a 
few months ago.135 

Conference vetting system 
The  discussions  on  the  appropriateness  of  direct  sponsorship  of  healthcare  professionals  has  been 
ongoing  for  many  years.  In  2010/2011,  after  questions  and  comments  from  companies,  the  industry 
started  thinking about a system for assessing whether  conferences are  professional or mainly leisure 
(and  hence  not  appropriate  for  sponsorship).  In  that  context,  the  conference  vetting  system  was 
developed and introduced in 2012. This system assesses, for the entire industry, which European and 
global conferences can be supported and which cannot. The system changed the conference landscape; 
the organisation of conferences has become more professional. To a certain extent, there was already 
an ongoing move towards that, but it seems that the conference vetting system, as well as the EFPIA 
system (similar system), helped to create a professional standard of what is an appropriate conference 
for  sponsorship.  Now,  with  the  phasing  out  of  direct  sponsorship  in  the  MedTech  industry,  using  the 
conference vetting system remains a requirement for determining for which conferences an educational 
grant is provided. 

4.3.3.  Theme 3: Double practice  
As  is  illustrated  in  Figure  4.21,  countries  where  patients  are  asked  to  go  for  a  private 
consultation  in  order  to  be  treated  in  a  public  hospital  are,  in  particular:  Malta  (67%), 
Ireland (36%), Spain (31%), Austria (28%), Denmark (23%), France (20%) and Romania 
(19%), while the EU27 average is 12%.136  

133 The study team was, notwithstanding several requests to EFPIA, unable to arrange an interview with EFPIA. 
134 The Disclosure Code and other EFPIA self-regulation can be found here: http://transparency.efpia.eu/the-
efpia-code-2.  
135 See for example https://www.taylorwessing.com/synapse/ti-new-anti-bribery-law-german-healthcare-
sector.html for more information. 
136 Special Eurobarometer 397, 2014, p.92. 

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Figure 4.21  Double practice 
You were asked to go for a private consultation in order to be treated in a public hospital?  

Source: Special Eurobarometer 397, 2014, QB3, T5 

>30% 

20 – 29% 

10 – 19% 

1 – 9% 

0% 

These results suggest that the problem of double practice is not isolated to Member States, 
with a high perception of corruption (in healthcare); as Figure 4.22 shows, there is no clear 
correlation of experiences with double practice with general perceptions of corruption in 
the healthcare sector. 

Figure 4.22  No (clear) correlation between perceptions of corruption in healthcare and 
experiences with double practice 
Y-axis: % of respondents that think that the giving and taking of bribes and the abuse of power for personal 
gain are widespread in healthcare; X-axis: % of respondents that has been asked to go for a private 
consultation in order to be treated in a public hospital. 

Source: Ecorys 2016, derived from Special Eurobarometer 397, 2014 (fieldwork February - March 2013), Table 
QB7 and QB3 (You were asked to go for a private consultation in order to be treated in a public hospital) 

Countries where patients have most frequent experiences paying for privileged treatment 
are: Slovakia (41%), Slovenia (38%) and Germany, Spain, France and Sweden (all 29%), 

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while  the  EU  average  stands  at  19%.137  As  the  Figure  below  shows,  there  is  no  clear 
correlation with general perceptions of corruption in the healthcare sector.  

Figure 4.23  No (clear) correlation between perceptions of corruption in healthcare and 
experiences with bribery for preferred treatment 
Y-axis: % of respondents that think that the giving and taking of bribes and the abuse of power for personal 
gain are widespread in healthcare; X-axis: % of respondents that have been asked to pay for a privileged 
treatment. 

Source: Ecorys 2016, derived from Special Eurobarometer 397, 2014 (fieldwork February - March 2013), Table 
QB7 and QB3 (You were asked to pay for a privileged treatment). 

Survey results 

44% of the survey respondents (11 in total) indicated that double practice occurs often or 
all  the  time  in  their  country.  40%  (10  in  total)  indicated  that  double  practice  happens 
sometimes or occasionally, while only one respondent indicated that double practice never 
happens. Three respondents were not able to answer the question.  

Table 4.19 

Answers given to statement on double practice (n=25) 

Does double practice in public and private clinics frequently occur in your 
country? (n=25) 
5 All the time  
4 Often  
3 Sometimes 
2 Occasionally 
1 Never 
- Do not know 

Total 

5 
6 
8 
2 
1 
3 

As presented in the Figure below, double practice seem to be most common in both the 
Mediterranean region (58%) and North West Europe (50%), while in Eastern Europe double 
practice  only  occurs  often  (as  opposed  to  all  the  time),  according  to  30%  of  the 
respondents.  Eastern  Europe  is  the  only  region  where  respondents  indicate  that  double 
practice never occurs.  

137 Special Eurobarometer 397, 2014, p.92. 

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Figure 4.24  Geographical spread for double practice (n=25) 

The number of respondents in each group: n= 7 (group 1), n= 10 (group 2), n= 8 (group 3). 

The majority of the stakeholders, 76%, are not aware of specific policies and practices to 
prevent  and  control  double  practice  in  their  country.  The  remaining  23%  indicated  that 
they are aware of such policies and practices.  

Are you aware of specific policies and practices to prevent and control double 
practice in your country? (n=26) 
Yes 
No  

Total 

6 
19 

Fact finding missions  

The problem of double practice is a relatively new problem in Greece. Until some years ago 
physicians in hospitals used to be employed fully as civil servants. As a consequence, they 
were not allowed to work in the private sector as well. Currently, some physicians have 
other types of contracts, which allow them to work, under conditions, in both the public 
and  private  sector.  Moreover,  some  public  physicians  (still  being  civil  servants)  are  also 
illegally active in the private sector.  

In Croatia, it is not possible for physicians to hold a private practice in public hospitals, but 
physicians can work in both public and private hospitals. Double practice is considered a 
problem, because the physicians working in private clinics do not have enough energy to 
perform their work properly at the public hospitals. People prefer private hospitals because 
they are quicker and more efficient. This may be problematic with regard to equal access. 
Stakeholders,  however,  support  the  combination  of  public  and  private  healthcare,  and 
some even argued that having private practice could lower waiting lists in public hospitals. 

In Lithuania it is actually very common, and legal, for physicians to have multiple positions 
in the public and private sector. It is difficult to estimate the effect that this has on the 
healthcare sector. In an effort to further look into this, the Ministry of Health undertook to 
determine how many physicians had dual positions (in 2015). This was done by comparing 

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data from the tax authorities with data declared on the basis of the 2014 Law on Private 
Interest (which states that all physicians had to declare their interests in 2015 to the Chief 
Official Ethics Commission). This comparison revealed that a large number of physicians 
had not declared all their interests, which made it impossible to accurately estimate the 
size  of  the  problem,  and  again  confirmed  the  need  to  further  investigate  the  issue  of 
double/ multiple practices..  

In Hungary double practice is allowed and most physicians engage in it. Although no update 
has  been  made  since  the  2013  study’s  data,  it  is  known  that  50%  of  patients  make  an 
informal  payment  for  hospitalisation  (with  an  average  worth  of  100  EUR),  and  20%  of 
patients make an informal payment worth 15 EUR for physician visits.138  

Working at the same time in a public and private hospital – double practice - is allowed 
under Polish law. Stakeholders indicated that allowing physicians to work in both sectors 
helped to combat informal payments, as physicians have the opportunity to increase their 
income in a legal way. Nevertheless, stakeholders also indicated that double practice could 
contribute  to  forms  of  corruption,  especially  to  privileged  access.  In  such  cases,  the 
physician  admits  patients  from  his  private  clinic  to  his  public  hospital,  helping  them  to 
bypass the long waiting lists.  

Double practice does occur in Romania. The main reason given for the existence of double 
practice is the low salaries of physicians. By working at both private and public hospitals, 
physicians  have  the  opportunity  to  increase  their  salary  with  additional  income.  Some 
stakeholders interviewed reported that private facilities are often used as recovery centres, 
while the actual treatment, e.g. surgery, takes place in the public hospital. As described in 
the country report on Romania, the Romanian government initiated a law that aimed to 
legalise  double  practice.  This  initiative  encountered  much  opposition  as  it  would  only 
benefit a minority of physicians, the ones with the highest salaries.  

EU-level interviews 

DG  SANTE  stated  that  double  practice  is  an  important  issue  as  it  relates  to  conflict  of 
interest issues, but is not acknowledged as being a problem by many Member States.  

138 See Baji P., Pavlova M., Gulácsi L., Farkas M., Groot W. (2014), The link between past informal payments 
and willingness of the Hungarian population to pay formal fees for health care services: results from a 
contingent valuation study. In European Journal of Health Economics 15(8): 853:67. 

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5.  CONCLUSIONS 

The objectives of this study were:  

  To  analyse  and  report  on  relevant  developments  in  the  areas  of  medical  service 
delivery,  procurement  and  certification  of  medical  devices,  and  procurement  and 
authorisation  of  pharmaceuticals  since  the  publication  of  our  initial  study  on 
corruption in the healthcare sector (SCH1, October 2013); 
  To provide an in-depth analysis of selected issues, including: 

-  Privileged access to medical services (including not only informal payments 

but also the use of privileged information and information peddling);  

-  Potential risks involving double practice in public and private clinics. 
- 

Improper  marketing  by  pharmaceutical  companies  and  medical  device 
producers  (at  national  and/or  EU  level,  including  for  market  authorisation 
and reimbursement approval); 

The study covers all EU-28 Member States with specific focus on Greece, Croatia, 
Hungary, Lithuania, Poland, and Romania. These are countries where the EU Anti-
Corruption Report highlights healthcare as an issue. Below, we highlight the main 
findings and conclusions per main part of the study. 

5.1.  Revisiting the general conclusions of SCH1 

In the initial study on Corruption in the Healthcare Sector (SCH1), 13 general conclusions 
were drawn. In the current study, stakeholders were asked, during the survey, fact-finding 
missions  and  interviews,  whether  they  believe  these  conclusions  are  still  relevant.  The 
consulted stakeholders added the following nuances to the conclusions on the phenomena 
of corruption in healthcare in itself and avenues to combat it:  

Conclusion 1: Convictions of (high-profile) corruption cases have a deterrent and norm-
setting effect. 
The majority of the stakeholders confirmed that this conclusion is still valid. However, in 
some countries hardly any cases are brought to court and this weakens the norm-setting 
effect. In addition, stakeholders mentioned that a norm-setting effect is only effective when 
it is followed up by sustained political action.  

Conclusion 2: Centralisation of procurement is a method to lower the risks of corruption. 
The  majority  of  the  stakeholders  consulted  agreed  (either  fully  or  to  some  extent)  that 
central procurement is a good method to lower the risks for corruption. Agreement with 
this  conclusion  is  stronger  in Eastern  and North  West  Europe  than  in the  Mediterranean 
countries.  

It was noted that it may also be important to have public registries in place and to introduce 
transparency increasing measures, otherwise centralised procurement may actually face 
more risks (also see “conclusion 3”).  

Conclusion 3: Central procurement systems can become vulnerable as targets for lobbyists 
and more politically inspired types of corruption.  
The  majority  of  the  stakeholders  agreed  with  this  statement,  though  it  was  noted  that 
decentralised systems may also be prone to lobbying and politically inspired corruption. As 
with  conclusion  2,  for  conclusion  3  we  observed  regional  differences  in  the  stakeholder 
responses in the survey: the outcomes indicate that the risks on lobbying and politically 
inspired types of corruption are perceived to be higher in the Mediterranean and Eastern 
Europe area compared to North West Europe. 

Conclusion 4: Bribery in medical service delivery cannot be contested with only targeted 
policies against the phenomenon as such, but need to be supplemented with a variety of 
accompanying (structural) measures.  

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In  regions  where  bribery  in  medical  service  delivery  is  still  common,  the  majority  of 
stakeholders agreed that both targeted policies and structural measures are required to 
fight  the  problem.  Interviewees  indicated  a  wide  variety  of  necessary  accompanying 
measures, including: strengthening the judicial system, changes in the healthcare system, 
and changes in attitudes towards corrupt practices. In North West Europe, where this form 
of corruption is less common, only a minority of stakeholders expressed the need for more 
structural changes alongside targeted policies.  

Conclusion  5:  Raising  salaries  does  not  have  a  significant  preventive  effect  on  reducing 
bribery in medical service delivery. 
Low salaries are indeed a problem according to the majority of the stakeholders. However, 
the  majority  of  respondents  in  all  regions  agreed  that  raising  salaries  cannot  be  a 
standalone  measure.  For  example,  it  was  mentioned  that  active  prosecution  and  public 
awareness of the unethical aspects are also needed. 

Conclusion 6: There is more than one root cause of corruption in healthcare.  
Survey  results  showed  that  the  most  frequently  mentioned  root  causes  are:  a  general 
acceptance  of  corruption,  ineffective  managerial  structures,  inappropriate  financing 
mechanisms, and unequal allocation of resources. Respondents also mentioned insufficient 
healthcare capacity, and insufficient funding for independent medical research as causes 
for corruption. 

Conclusion 7: The introduction of transparent waiting lists has a positive effect on reducing 
healthcare bribery. 
Most stakeholders agreed that introducing transparent waiting lists would have a positive 
effect on healthcare bribery. However, recent attempts to reduce such lists have not been 
successful in all countries, due, for example, to the fact that the lists were not frequently 
updated which resulted in outdated information being supplied to patients.  

Conclusion 8: Prescription of generics instead of branded pharmaceutical products has a 
positive effect on reducing healthcare bribery. 
The majority of respondents are of the opinion that the prescription of generics instead of 
branded  pharmaceutical  has,  at  least  to  some  extent,  a  positive  effect  on  reducing 
healthcare bribery. Particularly in Eastern Europe, where several countries have introduced 
this type of policy, the majority of people agree to the statement. However, our research 
has shown that in practice, this measure has had a minimal impact so far, or only reduces 
bribery to some extent.  

Conclusion 9: Self-regulation between the industry and healthcare providers is needed to 
fight corruption in healthcare. 
The  vast  majority  of  stakeholders  agreed  that  self-regulation  is  an  instrument  to  fight 
corruption.  Looking  at  the  different  regions,  it  stands  out  that  stakeholders  in  Eastern 
European countries appear to be the most sceptical, and only expect self-regulation to be 
effective to ‘some extent’. Many stakeholders noted that self-regulation is important, but 
not  sufficient,  and  that  it  would  be  beneficial  if  initiatives  between  the  industry  and  the 
healthcare provider are embedded in legislation, for example, to strengthen enforcement 
mechanisms.  

Conclusion 10: Self-regulation among players (such as within the pharmaceutical industry 
or among physicians) is needed to fight corruption in healthcare. 
The majority of the stakeholders agreed that self-regulation among players is important. 
Compared to ‘conclusion 9’ there is relatively little geographical variation in the responses 
of  stakeholders.  As  with  self-regulation  between  the  industry  and  healthcare  providers 
(conclusion 9), stakeholders note that it is not sufficient by itself and that incentives for 
cooperation are important for self-regulation to be effective.  

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Conclusion 11: Awareness raising campaigns and fraud and corruption reporting hotlines 
are an effective instrument to fight corruption in healthcare. 
Most stakeholders agreed that awareness campaigns and reporting hotlines are effective 
instruments in the fight against corruption. Nevertheless, some interviewees stressed that 
many  patients  do  not  report  to  such  hotlines,  and  therefore  many  cases  might  remain 
unknown. Also, reporting hotlines alone cannot be effective in reducing corruption; they 
need to be combined with other measures and legislation to fight corruption.  

Conclusion 12: The government should play a (more) active role in creating transparency 
in the relations between the industry and healthcare providers. 
According to the vast majority of the stakeholders, the government should play a (more) 
active  role  in  creating  transparency  in  the  relations  between  industry  and  healthcare 
providers. The respondents in North West Europe are the most positive about the role the 
government  could  play  in  this.  In  our  research,  we  encountered  incidental  scepticism 
regarding the role of the government when governments do not show sufficient willingness 
to fight corruption in general.  

Conclusion 13: The importance of active – independent – media involvement and pressure 
form ‘civil society’ watchdogs is essential to fight corruption in healthcare. 
Media  involvement  and  civil  pressure  are  generally  considered  as  essential  to  fight 
corruption, also by the stakeholders involved in this study: the vast majority agreed with 
the statement at least to least some extent. Though it is considered an important tool in 
the  fight  against  corruption,  our  research  shows  that  there  is  a  difference  between 
countries regarding the countervailing power of these ‘watchdogs’. 

5.2.  Relevant developments since SCH1 

Bribery in medical service delivery 

Bribery in medical service delivery - also referred to as ‘petty corruption’, ‘under-the-table 
payments’, or ‘informal payments’ – was one of the main typologies identified in SCH1; 
and one of the most prevalent and visible forms of corruption, especially in Eastern and 
Southern European Member States.  

The results of the current study reveal that bribery in medical service delivery remains one 
of the main challenges, especially in many Eastern and Southern European Member States. 
Root causes mentioned for most countries include general acceptance of bribery, low wages 
for  health  professionals,  including  physicians,  ineffective  managerial  structures,  and 
ineffective control mechanisms.  

When considering possible ways to fight bribery in medical service delivery, both the survey 
results  as  the  results  from  the  interviews  indicate  that  raising  salaries  of  health 
professionals  will  not  be  sufficient  in  itself.  The  majority  of  consulted  stakeholders  also 
agree that petty corruption cannot be combatted by policies targeted at the phenomenon 
as such, but needs to be combined, or preceded, by structural measures in the healthcare 
system, including transparency enhancing measures (e.g. transparency of waiting lists). 
In  addition,  (media  coverage  of)  prosecution  of  cases  can  have  a  deterrent  and  norm-
setting effect. The vast majority of survey respondents and interviewees – both during the 
fact finding missions and at EU-level – acknowledged the importance of this norm-setting 
effect. An important precondition is the existence of proper checks and balances; in many 
Member  States  the  disciplinary  board  overseeing  control  currently  consists  of  only 
physicians and this is considered rather ineffective. 

Common developments in the six focus countries include an increase in awareness raising 
campaigns and the fact the prosecution of physicians for bribery in medical service delivery 
has,  over  the  last  few  years,  become  more  common.  There  are,  however,  significant 
differences  between  Member  States  in  terms  of  their  efforts,  as  well  as  successes,  in 

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fighting  petty  corruption.  For  example,  much  progress  was  made  in  Poland:  bribery  in 
medical service delivery is currently less accepted by society. This is expected to be the 
result of a combination of awareness raising campaigns, active prosecution of physicians, 
and  media  coverage  of  these  cases.  In  Greece,  on  the  other  hand,  the  situation  has 
worsened as a result of the economic downturn. Increasing demand for public healthcare 
(as patients can no longer afford private care) in combination with decreasing salaries for 
physicians, leads to a situation in which more informal payments are requested. In other 
Member  States  the  situation  appears  to have stayed  more  or  less  the  same  in  terms  of 
occurrence, despite efforts to fight bribery in medical service delivery.  

A promising, though slow moving, development that is observed in the countries visited 
for this study is that younger generations – both physicians and patients – no longer accept 
bribery in medical service delivery as common practice. The countries show a generational 
shift  in  terms  of  mentality  towards  informal  payments;  this  mentality  is  generally 
acknowledged to be one of the most difficult causes to fight petty corruption. 

Corruption in procurement of medical devices and pharmaceuticals 

In our initial study we concluded that corruption in procurement often takes place during 
the  early  stages  of  the  process,  most  commonly  by  tailoring  the  tender  specifications 
and/or  the  tender  phase  to  one  (preferred)  supplier.  One  of  the  proposed  solutions  to 
mitigate the risks for this type of corruption is centralisation of procurement processes. An 
important  precondition  for  this  measure  to  be  effective  is  transparency  in  the  central 
corruption’s  natural  enemy139”.  Without 
procurement  body: 
transparency,  increasing  pressure  from,  for  example,  lobbyists  and  conflicts  of  interest, 
may actually increase the risks for corruption.  

“transparency…is 

In this study we found that stakeholders differ in their view on whether or not centralising 
procurement will reduce corruption risk. More than half of the survey respondents believe 
that  centralisation  is  indeed  an  effective  method  for  lowering  the  risk  for  corruption  in 
procurement, but over 70% of the respondents also indicate that centralisation comes with 
risks. Hence, the effectiveness will depend on the way in which the system is implemented. 
The  system  in  Hungary  is  an  example  of  why  combining  centralised  procurement  with 
transparency is essential for success; to date no transparency enhancing measures have 
been introduced in Hungary and hence stakeholders believe that the situation has actually 
worsened compared to the former (decentralised) system. There are also countries facing 
challenges in a decentralised system: individual physicians are made responsible for their 
own procurement without having the knowledge to do this (efficiently). This information 
asymmetry between healthcare providers and industry create risks for corruption.  

We also found that several Member States have implemented other measures to reduce 
the  risk  of  corruption  in  the  procurement  of  medical  devices  and  pharmaceuticals.  One 
example  is  the  online  publication  of  procurement  data  in  Croatia  and  Lithuania.  In 
Lithuania,  the  Ministry  of  Health  is  also  encouraging  hospitals  to  collaborate  in  order  to 
enable  larger  procurements  and  to  reduce  the  bargaining  power  of  the  industry.  In 
Romania and Greece, anti-corruption bureaus/directorates have been set-up to look into 
this type of corruption. Finally, we mention the price observatory for medical supplies in 
Greece  as  an  example:  this  list  indicates  the  maximum  prices  that  can  be  charged  to 
hospitals. 

139 https://www.neweurope.eu/article/transparency-corruptions-natural-enemy/ 

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Privileged access & double practice 

Gaining  privileged  access  to  healthcare  services  is  not  only  achieved  through  informal 
payments,  but  also  through  informal  relations  or  information  peddling.  The  fact-finding 
mission in Lithuania, for example, revealed that informal relations play an important role 
in gaining access to healthcare; from family doctor visits to tertiary hospital services. As 
there is no comparable data on the topic available, transparency with regard to the level 
of access to healthcare services is further complicated.  

Double practice, i.e. physicians working both in the public and private sector, also creates 
risks for corruption. In some countries misuse of double practice goes hand in hand with 
privileged access. For example, in Greece, Romania and Poland stakeholders described the 
following  link  between  double  practice  and  privileged  access.  A  patient  first  visits  the 
physician in his/her private clinic and pays him/her through private insurance as well as 
via under-the-table payment (i.e. double payment). Once the physician is paid, the patient 
is admitted directly to the public hospital and he/she is placed higher on the waiting list. 
Hence,  by  visiting  the  physician  in  a  private  clinic,  waiting  lists  in  public  hospitals  are 
bypassed.  

Compared to bribery in medical service delivery, corruption related to granting privileged 
access to healthcare or potential risks involving double practice occur much more randomly 
and are not (clearly) correlated with general perceptions of corruption (in the healthcare 
sector).  

Survey  results  indicate  that  over  75%  of  the  respondents  is  not  aware  of  any  specific 
policies or practices to control double practice in their country. Moreover, the fact-finding 
missions revealed that in many of the countries studied in more depth, double practice is 
not  illegal,  and  sometimes  even  considered  a  good  thing  as  it  may  reduce  informal 
payments and/or decrease waiting lists in the public sector. Nevertheless, the risk of double 
practice is acknowledged and some countries are looking into how to mitigate these risks, 
without prohibiting physicians from working in both the public and the private sector (e.g. 
Romania). 

Improper marketing  

Relationships  between  physicians  and  the  industry  are  necessary  and  beneficial  in  the 
context  of  product  development  and  monitoring  the  use  of  medicines  in  practice.  In 
addition,  industry  supports  continuous  medical  education  of  healthcare  professionals 
through  sponsorship.  Important  to  note  is  that  these  relationships  also  create  risks  for 
improper and corrupt practices, such as influencing prescribing behaviour. Such practices 
can  lead  to  inefficient  allocation  of  resources  or  even  healthcare  risks  when  certain 
medicines  or  devices  are  prescribed  or  used  for  reasons  other  than  proven  medical 
indications. 

In our initial study, improper marketing – in both the pharmaceutical and medical devices 
sectors - was identified as one of the main corruption in healthcare typologies, even though 
it was not one of the focus areas of that study. The initial study also revealed that both at 
the Member State and the EU level different measures were implemented to prevent and 
control  this  form  of  corruption. For  example,  through transparency enhancing  initiatives 
and  self-regulation  codes  of  conduct.  The  current  study  shows  that  improper  marketing 
remains  a  major  problem  area  and  often  occurs  in  many  countries.  Only  one  survey 
respondent indicated that improper marketing does not occur in his/her country.  

To prevent improper marketing, several (self-)regulation initiatives have been introduced. 
At  the  EU-level,  the  trade  associations  EFPIA  (pharmaceuticals)  and  MedTech  Europe 
(medical devices) have both introduced a new code since the publication of our initial study 
in  October  2013.  EFPIA  introduced  the  ‘Disclosure  Code’,  which  supplements  the  codes 

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already in place. This code states that EFPIA members should disclose, on their websites, 
the  transfers  of  value  given  to  healthcare  professionals  and  healthcare  officers. 
Enforcement  of  the  Code  is  discharged  by  the  member  associations.  MedTech  Europe 
introduced  the  Code  of  Ethical  Business  practices,  which  came  into  effect  on  1  January 
2017. One of the main points in this Code is the phasing out of direct sponsorship. Many 
of the multinational members of the association have already implemented the Code, and 
the national organisations are currently in the process of transposing it.  

Both the EFPIA and MedTech Europe Code were mentioned in the interviews that took place 
as part of the fact finding missions. The transposition of the codes by national organisations 
was  sometimes  mentioned  to  be  challenging, for  example  because  direct  sponsorship  is 
allowed and/or transparency is not required under national law. In addition, there are some 
countries where the legislation is stricter than the self-regulation codes, or ambiguous with 
regard to specific aspects of the code, which makes it difficult to determine how the two 
can coexist.  

In  addition  to  the  transposition  of  the  EFPIA  and  MedTech  Europe  Code,  there  are  also 
other initiatives at the national level to prevent improper marketing. In many countries, 
the  national  associations  have  introduced  a  code  of  conduct  or  ethics  or  transparency 
enhancing initiatives. Self-regulation appears to play an important role in the fight against 
improper marketing. Over two-thirds of the survey respondents agreed that self-regulation 
among players is needed. Moreover, over 80% of these respondents also indicated that 
the government should play a (more) active role in creating transparency, especially with 
regard to combining self-regulation measures with formal legislation.  

As stated above, it is also important to consider the risks associated with lobbying when 
talking about improper marketing. While lobbying is in itself not a bad thing, it may create 
risks  if  conducted  improperly.  In  2015,  Transparency  International  published  a  report 
about lobbying practices in 19 countries and three EU institutions. The results show that in 
only  seven  out  of  the  19  countries  included  in  the  study  there  is  dedicated  lobbying 
regulation.  In  addition,  the  study  reveals  that  58%  of  EU  citizens  believe  that  “their 
country’s government is to a large extent or entirely controlled by a few big interests”. The 
importance of legislation on lobbying practices was acknowledged during the fact finding 
missions. For example, in Lithuania the Minister of Health recently expressed concern about 
the lack of regulation on this issue as it creates big risks for corruption. In Poland, there is 
self-regulation by governmental organisations, specifying for which costs civil servants can 
be reimbursed by the industry to mitigate the corruption risks.  

An example of a policy that was implemented by several national governments is the policy 
that  physicians  can  only  prescribe  active  substances,  not  branded  medication. 
Stakeholders are not unanimous in their opinion as to whether or not this policy will help 
to prevent improper marketing. In the survey, 60% of the respondents indicated that this 
policy will help to reduce corruption risks, at least to some extent. This was acknowledged 
by several EU-level interviewees, who in turn also stressed that this policy alone will not 
be  enough.  The  fact-finding  missions  confirmed  this  notion.  For  example,  in  Greece, 
Croatia,  Poland  and  Romania,  stakeholders  mentioned  that  although  the  policy  has 
potential, and seems to have some effect; physicians sometimes still find ways to prescribe 
branded  products,  and  industry  can  shift  their  influencing  efforts  from  physicians  to  the 
officials responsible for determining the reimbursement list. 

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Annex I: Interview guide 

Study on corruption in the healthcare sector II – INTERVIEW GUIDE 

This interview guide is part of an independent research of Ecorys Nederland B.V. (project leader: 
Dr. Brigitte Slot) on corruption in the healthcare sector. The project is commissioned by the 
European Commission, Directorate General Migration and Home Affairs (DG Home).  
The fight against corruption is one of the key priorities for the EC. Corruption is defined as “the 
abuse of power for private gain” – this is a wide definition that also encompasses aspects that go 
beyond the criminal law aspects, including situations such as conflict of interest, favouritism, etc.  

The current study aims to:  

  Update the results of the previous study;  
  Collect information on selected thematic issues 
Informal payments in medical service delivery; 
- 
-  Certification and procurement of medical devices; 
-  Authorisation and procurement of pharmaceuticals; 
-  Privileged access to medical services (including not only informal payments but also the 

- 

use of privileged information and information peddling);  
Improper marketing by pharmaceutical companies and medical device producers (at 
national and/or EU level, including for market authorisation and reimbursement 
approval); 

-  Potential risks involving double practice in public and private clinics. 
 

Focus on selected countries: Croatia, Greece, Hungary, Lithuania, Poland and Romania. 

Purpose of the interview 

The purpose of the interview is to get detailed insights into the current situation regarding the 
extent, nature and impact of corrupt practices as well as legal and policy mechanisms to prevent 
and combat corruption at EU and/or MS level.  

The information provided during the interview will be treated confidentially. The interview report, 
summarising the main points discussed, will be sent back to the interviewees for validation. These 
interview reports will serve as an input for the final report, but will not be published in the report. 
Quotes that will be included in the report will not be traceable to individual interviewees. The final 
report will provide an overview of all the interviews conducted. This overview will contain the following 
information:  

  Member State (if applicable); 
  Date of the interview;  
 

Stakeholder category (e.g. patients, payers, industry, providers, regulators, civil society 
organization, anti-corruption agency); 

- 
- 

Interviewees will not be named personally; 
The name of the organisation the interviewee represents will only be named if the 
interviewee explicitly gives consent for this.   

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QUESTIONS 

A.  Introduction and general questions 

  Can you give a brief introduction on your organisation and your role within the 

organisation? 

Please note that corruption is much broader than paying or receiving bribes, transferring 
kickbacks or diverting (health care) funds. You are asked to adopt a broad 
perspective on corruption.  

For this study we are in interested in more 'direct' forms of corruption, but also in more 
indirect forms of corruption such as conflict of interest, trading in influence, revolving 
door policies and regulatory capture. In addition, with relation to corruption in 
procurement of medical supplies and pharmaceuticals, various forms of collusion (such as 
bid-rigging- price fixing or market division) may be relevant.  

We are interested in so-called 'petty corruption' (paying and receiving small sums or 
informal payments by individual clients) to large single corruption cases (for example in 
procurement of medical equipment) up to state capture types of corruption in health 
care.  

Another relevant angle is to analyse to which extent corruption is systematised within a 
society or economic (sub) sector. It is important to asses to what extent corruption 
should be considered as deviant behaviour (isolated corruption cases) or to what extent 
various forms of corruption are considered as normal practice (systematic corruption).  

  What are the most prevailing types of corruption in the healthcare sector? 
  What are the causes and/or risks of corruption in general, and specifically for 

the healthcare sector?  

  What is the impact of corruption in the healthcare sector?  

In the following sections we focus on: 

- Questions that are related to the recent cases of corruption in the healthcare 
sector (section B) 

- Questions that are related to legislation, specific policies and practices to 
prevent and control corruption (section C) 

- Questions that are related to the general conclusions of the 2013 Corruption 
in the Healthcare study140 (section D) 

B.  Recent cases ...............................................................................................   

  Are you aware of any recent cases of corruption in the healthcare sector (since 

2013)? 

  Are these related to any of the following issues: 
Informal payments in medical service delivery; 
- 
-  Certification and procurement of medical devices; 
-  Authorisation and procurement of pharmaceuticals; 
-  Privileged access to medical services (including not only informal payments but 

also the use of privileged information and information peddling);  

140 http://ec.europa.eu/dgs/home-affairs/what-is-
new/news/news/docs/20131219_study_on_corruption_in_the_healthcare_sector_en.pdf.  

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- 

Improper marketing by pharmaceutical companies and medical device 
producers (at national and/or EU level, including for market authorisation and 
reimbursement approval); 

-  Potential risks involving double practice in public and private clinics. 
  Could you provide details on the cases (including e.g. main actors, whether or 

not it was proven in a court or rather a suspicion of fraud)? 

C.  Policies and practices to prevent and control corruption ..........................   

  Which specific policies and practices and/or legislation to prevent and control 

corruption are in place (since 2013) at EU and/or Member State level? 
-  generic anti-corruption policies and practices; 
-  generic health care policies and practices; 
-  corruption-in-health policies: 

  Are these related to any of the following issues: 

Informal payments in medical service delivery; 
 
  Certification and procurement of medical devices; 
  Authorisation and procurement of pharmaceuticals; 
  Privileged access to medical services (including not only informal 

 

payments but also the use of privileged information and 
information peddling);  
Improper marketing by pharmaceutical companies and medical 
device producers (at national and/or EU level, including for market 
authorisation and reimbursement approval); 

  Potential risks involving double practice in public and private 

clinics. 

  Are there any examples of good practices (e.g. government actions, legal 
initiatives, policy changes, regulation, self-regulation etc.) at EU and/or 
Member State level to prevent and/or combat corruption (regarding the issues 
mentioned above) (since 2013)? 

D.  General conclusions of the 2013 report 

  Below we provide the general conclusions of the 2013 Corruption in the 

Healthcare study. Please could you indicate for each statement to what extent 
this is (still) applicable and why.  

Yes 

To some 
extent 

No  Don’t 
know 

Convictions of (high-profile) corruption cases have a deterrent 
and norm-setting effect. 
Centralisation of procurement is a method to lower the risks of 
corruption. 
Central procurement systems can become vulnerable as target 
for lobbyist and more political inspired types of corruption. 
Bribery in medical service delivery cannot be contested with 
only targeted policies against the phenomenon as such, but 
need to be supplemented with accompanying (structural) 
measures. 
Raising salaries does not have significant preventive effect on 
reducing bribery in medical service delivery. 
The root causes of corruption in healthcare are related to: 
Ineffective managerial structures; 
Inappropriate financing mechanisms; 
Insufficient healthcare capacity; 
Insufficient funding for independent medical 
research; 

 
 
 
 

  Unequal allocation of resources; 
  A general acceptance of corruption in society; 
  Other root causes, please clarify. 

The introduction of transparent waiting lists has a positive 
effect on reducing healthcare bribery. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Yes 

To some 
extent 

No  Don’t 
know 

Prescription of generics instead of branded pharmaceutical 
products has a positive effect on reducing healthcare bribery. 
Self-regulation between the industry and healthcare providers 
is needed to fight corruption in healthcare. 
Self-regulation among players (such as within the 
pharmaceutical industry or among doctors) is needed to fight 
corruption in healthcare. 
Awareness raising campaigns and fraud and corruption 
reporting hotlines are an effective instrument to fight 
corruption in healthcare. 
The government should play a (more) active role in creating 
transparency in the relations between the industry and 
healthcare providers. 
The importance of active – independent – media involvement 
and pressure form ‘civil society’ watchdogs is essential to fight 
corruption in healthcare. 

  Do you have any final remarks or suggestions for our study?  

Thank you! 

152 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Annex II: Overview of survey stakeholders 

Table AII.1 Overview of survey stakeholders 
Country 

Organisation category 

Stakeholder 
category 
Industry 

Austria 

Industry 

Austria 

Industry 

Austria 

Industry 

Austria 

Industry 

Belgium 

National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EFPIA  

National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  

Industry 

Belgium 

National associations that are a member of EFPIA  

Industry 

Belgium 

Industry 

Bulgaria 

Industry 

Bulgaria 

Industry 

Czech Republic 

Industry 

Czech Republic 

Industry 

Czech Republic 

Industry 

Denmark 

National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  

Industry 

Denmark 

Industry 

Denmark 

National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EFPIA  

Industry 

Denmark 

National associations that are a member of the European Generic 
and Biosimilar Medicines Association  

153 

Organisation 

austromed  

ODGH  

Fachverband der Chemischen Industrie Österreichs 
(FCIO) 
OeGV (Austria) 

UNAMEC  

pharma.be (Association Générale de l'industrie du 
Médicament) 
FeBelGen (Belgium) 

BAMDE  

BGPharmA (Bulgaria) 

CzechMed  

CAFF (Czech Republic) 

CZEDMA  

DiaLab Denmark  

Medicoindustrien  

Laegemiddelindustriforeningen The Danish Association of 
the Pharmaceutical Industry (LIF) 
IGL (Denmark) 

 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

Stakeholder 
category 
Industry 

Industry 

Industry 

Industry 

Finland 

Finland 

Finland 

Finland 

Industry 

France 

Industry 

France 

Industry 

Germany 

Industry 

Germany 

Industry 

Germany 

Industry 
Industry 
Industry 

Germany 
Germany 
Germany 

Industry 

Ireland 

Industry 

Industry 

Industry 

Industry 

Ireland 

Italy 

Italy 

Italy 

Industry 

Netherlands 

Industry 

Netherlands 

Industry 

Netherlands 

Industry 

Netherlands 

National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of COCIR  

Sialab 

FiHTA  

National associations that are a member of EFPIA  

Lääketeollisuus ry / Pharma Industry Finland (PIF) 

National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of COCIR  
National associations that are a member of COCIR  
National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EFPIA  

FGA (Finland) 

SNITEM  

GEMME (France) 

BVMed  

SPECTARIS  

VDGH  

bvitg 
ZVEI  
Progenerika (Germany) 

IMDA  

Irish Pharmaceutical Healthcare Association (IPHA) 

National associations that are a member of EFPIA  

Associazione delle imprese del farmaco (Farmindustria) 

National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of COCIR  

Assobiomedica  

AssoGenerici (Italy) 

DIAGNED  

FHI  

Nefemed  

Holland Health Tech  

154 

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

Stakeholder 
category 
Industry 

Netherlands 

National associations that are a member of EFPIA  

Industry 

Netherlands 

Industry 

Portugal 

Industry 

Portugal 

Industry 

Portugal 

Industry 

Romania 

Industry 

Slovakia 

Industry 

Slovakia 

Industry 

Slovenia 

Industry 

Industry 

Spain 

Spain 

Industry 

Sweden 

Industry 

Sweden 

Industry 

Sweden 

Industry 

Sweden 

Industry 

Industry 

Industry 

UK 

UK 

UK 

National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EFPIA  

National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EFPIA  

National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of EUCOMED or EDMA – 
medical devices and in vitro diagnostics industry  
National associations that are a member of COCIR  

Vereniging Innovatieve Geneesmiddelen Nederland 
(Nefarma) 
BOGIN (Netherlands) 

APIFARMA  

APORMED  

APOGEN (Portugal) 

AFPM  

SEDMA  

SK-MED  

SLO-MED  

FENIN  

Asociación Nacional Empresarial de la Industria 
Farmacéutica (Farmaindustria) 
Swedish Labtech  

Swedish Medtech  

Läkemedelsindustriföreningen / The Swedish Association 
of the Pharmaceutical Industry (LIF/Sweden) 
FGL (Sweden) 

ABHI  

BIVDA  

AXrEM  

 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

National associations that are a member of the European Generic 
and Biosimilar Medicines Association  
University 

BGMA (United Kingdom) 

Medical University of Varna 

UK 

Bulgaria 

Denmark 
France 
Germany 
Germany 
Germany 
Ireland 
Italy 

Slovenia 
Sweden 

UK 
UK 
UK 
Austria 
Austria 
Belgium 

Belgium 
Bulgaria 

Bulgaria 

Bulgaria 

Bulgaria 
Cyprus 

Stakeholder 
category 
Industry 

Other  

Other  
Other  
Other  
Other  
Other  
Other  
Other  

Other  
Other  

Other  
Other  
Other  
Patients  
Patients  
Patients  

Patients  
Patients  

Patients  

Patients  

Patients  
Patients  

Patients  
Patients  
Patients  
Patients  
Patients  

European Association for Medical devices of Notified Bodies 
European Association for Medical devices of Notified Bodies 
European Association for Medical devices of Notified Bodies 
European Association for Medical devices of Notified Bodies 
European Association for Medical devices of Notified Bodies 
European Association for Medical devices of Notified Bodies 
Anti-corruption 

European Association for Medical devices of Notified Bodies 
European Association for Medical devices of Notified Bodies 

European Association for Medical devices of Notified Bodies 
European Association for Medical devices of Notified Bodies 
European Association for Medical devices of Notified Bodies 
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
EPF European Patients Forum  

Member of the European Consumer Organisation  
EPF European Patients Forum  

EPF European Patients Forum  

EPF European Patients Forum  

Member of the European Consumer Organisation  
EPF European Patients Forum  

www.presafe.dk 
www.gmed.fr 
www.dqs-medizinprodukte.de 
www.med-cert.com 
www.tuev-nord-cert.de 
www.nsai.ie 
Istituto per la Promozione dell'Etica in Sanità (ISPE-
Sanita) 
www.siq.si 
www.intertek.se 

www.intertek-acsl.com 
www.bisgroup.com 
www.lrqa.com 
Verein Fur konsumenteninforamtion - VKI  
Arbeiterkammer  
VPP - Flemish Patients’ Platform 

Test - Achats  
NPO - National Patients' Organisation of Bulgaria 
(Bulgaria) 
KZZ - Confederation Health Protections (Bulgaria) 

BAPD - Bulgarian Association for Patients Defence  

Bulgarian national association active consumers - BNAAC  
Pancyprian Federation of Patients Associations and 
Friends (Cyprus) 
Cyprus Conumers' Association - CCA  
dTest  
Forbrugerrådet Tænk  
EPIK - Estonian Chamber of Disabled People  
Estonian consumers union - Eesti tarbijakaitse LIIT  

Cyprus 
Czech Republic 
Denmark 
Estonia 
Estonia 

Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
EPF European Patients Forum  
Member of the European Consumer Organisation  

Patients  

Finland 

Member of the European Consumer Organisation  

Kuluttajaliitto-Konsumentförbundet ry 

156 

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

Stakeholder 
category 
Patients  
Patients  

Patients  
Patients  
Patients  
Patients  
Patients  

Patients  
Patients  
Patients  
Patients  

Patients  

Patients  

Patients  
Patients  
Patients  
Patients  

Patients  
Patients  

Patients  
Patients  
Patients  
Patients  
Patients  
Patients  
Patients  
Patients  

Finland 
France 

France 
France 
Germany 
Germany 
Ireland 

Ireland 
Italy 
Italy 
Latvia 

Member of the European Consumer Organisation  
EPF European Patients Forum  

Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
EPF European Patients Forum  

Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
EPF European Patients Forum  

Patients  

Latvia 

Member of the European Consumer Organisation  

Patients  

Lithuania 

EPF European Patients Forum  

Lithuania 

Member of the European Consumer Organisation  

The Finnish Competition and Consumer Authority (FCCA) 
CISS - Collectif inter associatif Sur la Santé  

UFC-Que choisir  
Consommation, logement et cadre de vie – CLCV  
Stiftung Warentest  
Verbraucherzentrale Bundesverband – vzbv  
MRCG - Medical Research Charities Group 

Consumers' Association of Ireland – CAI  
Consumatori Italiani per l'Europa (CIE)  
Altroconsumo  
SUSTENTO - The Latvian Umbrella Body for Disability 
Organization  
Latvian National Association for Consumer Protection - 
LPIAA  
LPOAT - Council of Representatives of Patients’ 
organizations of Lithuania (Lithuania) 
Alliance of Lithuanian Consumer Organisations  

Malta 

EPF European Patients Forum  

MHN - Malta Health Network (Malta) 

Malta 
Netherlands 
Portugal 
Romania 

Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
EPF European Patients Forum  

Romania 
UK 

Slovakia 
Slovakia 
Slovenia 
Spain 
Spain 
Spain 
Sweden 
UK 

Member of the European Consumer Organisation  
EPF European Patients Forum  

EPF European Patients Forum  
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
EPF European Patients Forum  
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
Member of the European Consumer Organisation  
EPF European Patients Forum  

Ghaqda Tal-Konsumaturi - CA Malta  
Consumentenbond  
Deco  
COPAC - Coalition of Patients' Organizations with Chronic 
Diseases  
Association for consumers' protection – APC  
The ALLIANCE - Health and Social Care Alliance Scotland  

AOPP - Association for the Protection of Patients' Rights 
Association of Slovak consumers  
Zveza Potrošnikov Slovenije - ZPS  
FEP - Spanish Patients’ Forum 
Confederación de consumidores y usuarios – CECU  
Organización de consumidores y usuarios – OCU  
Sveriges Konsumenter  
AMRC - Association of Medical Research Charities  

 
 
 
Stakeholder 
category 
Patients  
Patients  
Payer 

Payer 

Payer 

Payer 

Payer 

Payer 

Payer 

Payer 

Payer 
Payer 

Payer 
Payer 

Payer 
Payer 

Payer 
Payer 
Payer 

Payer 
Payer 

Payer 

Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

UK 
UK 
Austria 

Austria 

EPF European Patients Forum  
Member of the European Consumer Organisation  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  

Belgium 

Health insurance institute 

Belgium 

Belgium 

Belgium 

Belgium 

Belgium 

Bulgaria 
CzechRepublic 

CzechRepublic 
Estonia 

Finland 
Finland 

Finland 
France 
France 

France 
France 

France 

Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  

Members of the European Alliance in social insurance (ESIP)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Health insurance 
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  

Members of the European Alliance in social insurance (ESIP)  
Health insurance 
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  

Members of the European Alliance in social insurance (ESIP)  

158 

National Voices (United Kingdom) 
Which?  
Sozialversicherungsanstalt der Bauern (SVB)  

Hauptverband der österreichischen 
Sozialversicherungsträger, Vienna 
INAMI/RIZIV Rijksinstituut voor ziekte- en 
invaliditeitsverzekering 
MUTAS - Centrale d'Alarme Mutualiste  

Union Nationale des Mutualités Libérales  

Union Nationale des Mutualités Neutres (UNMN)  

Union Nationale des Mutualités Socialistes (UNMS)  

Office National des Pensions/Rijksdienst voor 
Pensioenen, Brussels 
National Social Security Insitute, Sofia 
Svaz zdravotních pojiš'oven (SZP)  

VZP (General Health Insurance Fund of Czech Republic) 
Estonian Health Insurance Fund (EHIF) "Eesti 
Haigekassa"  
Eläketurvakeskus, Helsinki 
FAII Federation of Accident Insurance Institutions, 
Helsinki  
TVR Työttömyysvakuutusrahasto, Helsinki 
CNAMTS (health insurance) 
Fédération Nationale de la Mutualité Française (FNMF)  

Caisse Centrale de la Mutualité Sociale Agricole, Paris 
Caisse Nationale des Allocations Familiales, Paris 

Caisse Nationale d'Assurance Maladie des Travailleurs 
Salariés, Paris 

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Stakeholder 
category 
Payer 
Payer 
Payer 
Payer 

Payer 

Payer 

Payer 

Payer 

Payer 
Payer 
Payer 
Payer 
Payer 
Payer 
Payer 
Payer 

Payer 
Payer 

Payer 
Payer 

Payer 

Payer 

Payer 

Payer 

Country 

Organisation category 

Organisation 

France 
France 
France 
Germany 

Germany 

Germany 

Germany 

Germany 

Germany 
Germany 
Germany 
Germany 
Germany 
Germany 
Germany 
Germany 

Germany 
Italy 

Italy 
Luxembourg 

Luxembourg 

Luxembourg 

Luxembourg 

Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  

Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  

Members of the European Alliance in social insurance (ESIP)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  
Health insurance 

Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  

Netherlands 

Health insurance 

Caisse Nationale d'Assurance Vieillesse, Paris  
Fédération Nationale de la Mutualité Française, Paris 
Régime Social des Indépendants, La Plaine Saint Denis  
BKK Dachverband e.V.  

Gemeinsame Vertretung der Innungskrankenkassen (IKK 
e.V.)  
Sozialversicherung für Landwirtschaft, Forsten und 
Gartenbau (SVLFG)  
Verband der Ersatzkassen e. V. (vdek)  

Arbeitsgemeinschaft Berufsständischer 
Versorgungseinrichtungen 
AOK-Bundesverband, Berlin  
BKK-DV BKK Dachverband, Berlin 
Gesetzliche Unfallversicherung, Berlin  
Deutsche Rentenversicherung Bund, Berlin  
GKV-Spitzenverband  
Interessenvertretung der Innungskrankenkassen, Berlin  
Knappschaft Bahn See, Hamburg  
Sozialversicherung für Landwirtschaft, Forsten und 
Gartenbau (SVLFG), Kassel  
Verband der Ersatzkassen e. V., Berlin  
Federazione Italiana Mutualità Integrativa Volontaria 
(FIMIV)  
INPS Istituto Nazionale della Previdenza Sociale, Rome  
CNS Luxembourg National Health Fund 

Caisse Médico-Chirurchicale Mutualiste  

Conseil Supérieur de la Mutualité Luxembourgeoise 
(CSM)  
ALOSS Association Luxembourgeoise des Organismes de 
Sécurité Sociale, Luxemburg  
Zorgverzekeraars Nederland (ZN) 

 
 
 
Updated Study on Corruption in the Healthcare Sector  

Stakeholder 
category 
Payer 
Payer 
Payer 
Payer 

Payer 
Payer 

Payer 

Payer 

Payer 

Providers  
Providers  
Providers  

Providers  
Providers  
Providers  

Providers  
Providers  
Providers  
Providers  
Providers  
Providers  
Providers  

Providers  
Providers  

Providers  
Providers  

Country 

Organisation category 

Organisation 

Netherlands 
Netherlands 
Netherlands 
Portugal 

Romania 
Slovakia 

Slovakia 

Slovenia 

UK 

Austria 
Austria 
Belgium 

Belgium 
Belgium 
Belgium 

Bulgaria 
Bulgaria 
Bulgaria 
Croatia 
Cyprus 
Cyprus 
CzechRepublic 

Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the European Alliance in social insurance (ESIP)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the European Alliance in social insurance (ESIP)  

Members of the International Association of Mutual Benefits 
Societies (AIM)  
Members of the International Association of Mutual Benefits 
Societies (AIM)  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
HOPE European Hospital and Healthcare Federation  

HOPE European Hospital and Healthcare Federation  
HOPE European Hospital and Healthcare Federation  
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
European Union of General Practitioners / family physicians 
HOPE European Hospital and Healthcare Federation  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
HOPE European Hospital and Healthcare Federation  

CzechRepublic 
CzechRepublic 

Members of the Standing Committee of European Doctors  
European Union of General Practitioners / family physicians 

SVB Sociale Verzekeringsbank, Amstelveen 
UWV Uitvoeringsinstituut Werknemersverzekeringen 
ZIN Zorginstituut Nederland, Diemen 
União das Mutualidades Portuguesas (UMP)  

NHIF/CNAS National Health Insurance Fund, Bucharest  
Všeobecná Zdravotná Pois'ov'a (VZP SR)  

SIA Social Insurance Agency/ Sociálna poistov?a, 
Bratislava  
Vzajemna Zdravstvena Zavarovalnica d.v.z  

Benenden  

Bundesministerium für Gesundheit 
Österreichische Ärztekammer 
Association Belge des Hôpitaux asbl/ Belgische 
Vereniging der Ziekenhuizen vzw 
Zorgnet-Icuro 
Fédération des Institutions Hospitalières asbl 
FINE - European Federation of Nurse Educators 

Association of Bulgarian Hospitals 
(Bulgarian Medical Association) 
Bulgaria - Bulgarian Medical Association 
Ministry of Health Croatia 
Ministry of Health  
Cyprus Medical Association 
ASOCIACE NEMOCNIC ČESKÉ REPUBLIKY (Czech 
Hospital Association) 
Czech Medical Chamber 
Associatoin of gerneral practitioners of Czech Replublic  

Denmark 
Denmark 

HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  

Danske Regioner 
Lægeforeningen 

160 

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

Denmark 

European Union of General Practitioners / family physicians 

Stakeholder 
category 
Providers  

Providers  

Denmark 

Providers 
Providers  
Providers  

Providers  

Providers  

Estonia 
Estonia 
EU 

EU 

EU 

Providers  

Finland 

Providers  
Providers  
Providers  

Providers  
Providers  

Providers  

Providers  
Providers  
Providers  
Providers  
Providers  

Finland 
Finland 
France 

France 
France 

France 

France 
Germany 
Germany 
Germany 
Germany 

Providers  

Germany 

Providers  
Providers  
Providers  
Providers  

Ireland 
Ireland 
Ireland 
Ireland 

Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
HOPE European Hospital and Healthcare Federation  

The Danish Medical Association (Den Almindelige 
Danske)  
EORNA - European Operating Room Nurses Association 

EESTI HAIGLATE LIIT 
Estonian Medical Association 
ECMH - European Conference on Mental Health 

IFNA - International Federation of Nurse Anesthetists 

EfCCNa - European federation of Critical Care Nursing 
associations 
Suomen Kuntaliitto Finlands Kommunförbund (The 
Association of Finnish Local and Regional Authorities) 

Members of the Standing Committee of European Doctors  
European Union of General Practitioners / family physicians 
HOPE European Hospital and Healthcare Federation  

Suomen Lääkäriilitto/Finlands Läkarförbund 
The Finnish Medical Association  
FHF 

HOPE European Hospital and Healthcare Federation  
HOPE European Hospital and Healthcare Federation  

HOPE European Hospital and Healthcare Federation  

Members of the Standing Committee of European Doctors  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
European Union of General Practitioners / family physicians 
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
European Union of General Practitioners / family physicians 
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  

Fédération Hospitalière de France 
UNICANCER 

Fédération Française des Centres de Lutte contre le 
Cancer 
Conseil National de l’Ordre des Médecins 
Deutsche Krankenhausgesellschaft (DKG) 
Bundesärztekammer 
The Finnish Medical Association  
ENDA - European Nurse Directors Association 

ESGENA - European Society of Gastroenterology and 
Endoscopy Nurses and Associate 
Independent Hospitals Association 
Irish Medical Organisation (IMO) 
Irish Medical Organisation (IMO)  
ACENDIO - Association for Common European Nursing 
Diagnoses, Interventions and Outcomes 

 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

Stakeholder 
category 
Providers  
Providers  
Providers  
Providers  

Providers  
Providers  
Providers  
Providers  

Providers  
Providers  
Providers  
Providers  
Providers  

Italy 
Italy 
Italy 
Latvia 

Lithuania 
Lithuania 
Luxembourg 
Luxembourg 

Malta 
Malta 
Malta 
Malta 
Netherlands 

HOPE European Hospital and Healthcare Federation  
European Union of General Practitioners / family physicians 
European Union of General Practitioners / family physicians 
HOPE European Hospital and Healthcare Federation  

HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  

HOPE European Hospital and Healthcare Federation  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
European Union of General Practitioners / family physicians 
Members of the Standing Committee of European Doctors  

Providers  

Netherlands 

Providers  

Portugal 

Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
HOPE European Hospital and Healthcare Federation  

Providers  
Providers  
Providers  

Portugal 
Romania 
Romania 

Members of the Standing Committee of European Doctors  
HOPE European Hospital and Healthcare Federation  
European Union of General Practitioners / family physicians 

Providers  

Romania 

European Union of General Practitioners / family physicians 

Providers  
Providers  
Providers  

Providers  
Providers  
Providers  
Providers  

Slovakia 
Slovenia 
Slovenia 

Spain 
Sweden 
Sweden 
Sweden 

HOPE European Hospital and Healthcare Federation  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  

HOPE European Hospital and Healthcare Federation  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
European Union of General Practitioners / family physicians 

162 

Regione del Veneto 
0 
0 
LATVIJAS SLIMNĪCU BIEDRĪBA 

LIETUVOS LIGONINIŲ ASOCIACIJA 
Lithuanian Medical Association 
Fédération des Hôpitaux Luxembourgeois 
Association des Médecins et Médecins-Dentistes du 
Grand-Duché de Luxembourg 
Ministry of Health, the Elderly and Community Care 
Department of Health 
Medical Association of Malta (MAM) 
The Malta College of Family Doctors  
Koninklijke Nederlandsche Maatschappij tot Bevordering 
der Geneeskunst – The Royal Dutch Medical Association 
(KNMG) 
EAUN - European Association of Urology Nurses 

Associação Portuguesa para o Desenvolvimento 
Hospitalar - APDH 
Ordem dos Médicos (O.M) 
Asociatia Spitalelor din România 
The Romanian College of Physicians: Romania’s 
reference organisation for the medical professions 

The Romanian College of Physicians: Romania’s 
reference organisation for the medical professions 
Asociácia Nemocníc Slovenska 
Združenje zdravstvenih zavodov Slovenije 
Zdravniška zbornica Slovenije 

Ministerio de Sanidad, Servicios Sociales e Igualdad  
SVERIGES KOMMUNER OCH LANDSTING 
Sveriges Läkarförbund 
The Swedish Medical Association  

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

Stakeholder 
category 
Providers  

Providers  
Providers  
Providers  
Providers  

Providers  

Providers  

Sweden 

UK 
UK 
UK 
UK 

UK 

UK 

Regulators  

Austria 

Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
HOPE European Hospital and Healthcare Federation  
Members of the Standing Committee of European Doctors  
European Union of General Practitioners / family physicians 
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
Members of the European Specialist Nurses Organisations (ESNO) 
(http://www.esno.org/members.php)  
National Competent Authorities Medical Devices 

Regulators  

Belgium 

EFHCN member 

Regulators  
Regulators  

Regulators  
Regulators  

Regulators  
Regulators  
Regulators  
Regulators  
Regulators  
Regulators  
Regulators  
Regulators  

Belgium 
Belgium 

Belgium 
Belgium 

National Competent Authorities Medical Devices 
National Competent Authorities Medical Devices 

European Medicines Agency, National Competent Authorities 
National Competent Authorities Medical Devices 

Bulgaria 
Bulgaria 
Bulgaria 
Croatia 
Croatia 
Cyprus 
Czech Republic 
Czech Republic 

European Medicines Agency, National Competent Authorities 
National Competent Authorities Medical Devices 
National Competent Authorities Medical Devices 
EFHCN member 
0 
National Competent Authorities Medical Devices 
European Medicines Agency, National Competent Authorities 
National Competent Authorities Medical Devices 

Regulators  
Regulators  

Denmark 
Denmark 

European Medicines Agency, National Competent Authorities 
National Competent Authorities Medical Devices 

EDTNA/ERCA - European Dialysis and Transplant Nurses 
Association / European Renal Care Association 
NHS Confederaton 
British Medical Association 
The British Medical Association 
EONS - European Oncology Nursing Society 

ERNA - European Respiratory Nurses Association 

ESE - European Society of Endocrinology Nurses 

Federal Ministry of Health, Dept. Pharmaceuticals and 
Medical Devices 
The Inter-mutualistic Agency (NIC/CIN) - IMA/AIM 

0 
IVDMD, Scientific Institute Public Health, Department 
Quality Medical Laboratories 
Federal Agency for Medicines and Health Products  
MDD AIMDD, Federal Agency for Medicines and Health 
Products Health Products Division 
Bulgarian Drug Agency  
0 
Bulgarian Drug Agency Department Medical devices 
Croatian Ministry of Health 
Republic Croatia  
Cyprus Medical Devices Competent Authority 
State Institute for Drug Control  
Ministry of Health Department of Pharmacy, Medical 
Devices Unit 
Danish Medicines Agency  
Danish Medicines Agency Pharmacovigilance and Medical 
Devices 
State Agency of Medicines  

Regulators  

Regulators  

Estonia 

Estonia 

European Medicines Agency, National Competent Authorities 

National Competent Authorities Medical Devices 

Health Board, Medical Devices Department 

 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

Stakeholder 
category 
Regulators  

Finland 

National Competent Authorities Medical Devices 

Regulators  

France 

National Competent Authorities Medical Devices 

Regulators  

Germany 

National Competent Authorities Medical Devices 

Regulators  

Germany 

National Competent Authorities Medical Devices 

Regulators  
Regulators  

Regulators  

Germany 
Germany 

Germany 

National Competent Authorities Medical Devices 
European Medicines Agency, National Competent Authorities 

National Competent Authorities Medical Devices 

Regulators  

Hungary 

National Competent Authorities Medical Devices 

Regulators  

Regulators  

Regulators  

Ireland 

Ireland 

Italy 

European Medicines Agency, National Competent Authorities 

National Competent Authorities Medical Devices 

Health Products Regulatory Authority 

National Competent Authorities Medical Devices 

Regulators  

Italy 

National Competent Authorities Medical Devices 

Regulators  
Regulators  
Regulators  
Regulators  
Regulators  

Regulators  
Regulators  
Regulators  
Regulators  
Regulators  
Regulators  
Regulators  

Latvia 
Latvia 
Lithuania 
Lithuania 
Lithuania 

Luxembourg 
Luxembourg 
Malta 
Malta 
Netherlands 
Netherlands 
Netherlands 

National Competent Authorities Medical Devices 
European Medicines Agency, National Competent Authorities 
EFHCN member 
European Medicines Agency, National Competent Authorities 
Regulator 

National Competent Authorities Medical Devices 
European Medicines Agency, National Competent Authorities 
European Medicines Agency, National Competent Authorities 
National Competent Authorities Medical Devices 
National Competent Authorities Medical Devices 
National Competent Authorities Medical Devices 
EFHCN member 

164 

Valvira - National Supervisory Authority for Welfare and 
Health 
Agence nationale de sécurité du médicament et des 
produits de santé (ANSM) 
Federal Institute for Drugs and Medical Devices, AIMDD 
CA 
Federal Ministry of Health (AIMDD, MDD, IVDMD 
Legislation) 
Paul Ehrlich Institute, IVDMD CA 
Federal Institute for Drugs and Medical Devices  

Zentralstelle der Länder für Gesundheitsschutz bei 
Arzneimitteln und Medizinprodukten (ZLG) (AIMDD, 
MDD, IVDMD Designating) 
Health Registration and Training Centre, Department of 
Medical Devices 
Health Products Regulatory Authority (HPRA)  

Ministry of Health, - Directorate General of Medical 
Devices and Pharmaceutical Services 
Ministry of Health, - Directorate General of Medical 
Devices and Pharmaceutical Services 
State Agency of Medicines 
State Agency of Medicines  
Lithuanian Ministry of Health 
State Medicines Control Agency  
Ministry of Health 

Ministère de la Santé, Direction de la Santé 
Ministry of Health  
Medicines Authority  
Malta Competition and Consumer Affairs Authority 
CIBG Farmatec-BMC, Front Office 
Dutch Healthcare Inspectorate 
Nederlandse Zorgautoriteit (NZa) 

 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Country 

Organisation category 

Organisation 

Stakeholder 
category 
Regulators  

Portugal 

National Competent Authorities Medical Devices 

Regulators  

Portugal 

EFHCN member 

Regulators  
Regulators  

Regulators  
Regulators  

Regulators  
Regulators  
Regulators  
Regulators  

Romania 
Romania 

Romania 
Romania 

Romania 
Slovakia 
Slovakia 
Slovenia 

EFHCN member 
National Competent Authorities Medical Devices 

National Competent Authorities Medical Devices 
Regulator  

Regulator 
National Competent Authorities Medical Devices 
European Medicines Agency, National Competent Authorities 
European Medicines Agency, National Competent Authorities 

Regulators  

Slovenia 

National Competent Authorities Medical Devices 

Regulators  

Spain 

National Competent Authorities Medical Devices 

Regulators  

Sweden 

National Competent Authorities Medical Devices 

Regulators  
Regulators  
Regulators  

Sweden 
UK 
UK 

European Medicines Agency, National Competent Authorities 
European Medicines Agency, National Competent Authorities 
National Competent Authorities Medical Devices 

Infarmed - National Authority of Medicines and Health 
Products, IP 
IGAS - General Inspectorate of Health 

Romanian Ministry of Health 
National Agency for Medicines and Medical Devices 

National Agency for Medicines and Medical Devices 
Municipality Commission on Healthcare and Social 
Services 
Ministry of Health 
State Institute for Drug Control, Medical Devices Section 
State Institute for Drug Control  
Agency for Medicinal Products and Medical Devices of the 
Republic of Slovenia  
Agency for Medicinal Products and Medical Devices of the 
Republic of Slovenia 
Agencia Espaňola de Medicamentos y Productos 
Sanitarios 
Medical Products Agency´ 'Läkemedelsverket' Medical 
Devices 
Medical Products Agency  
Medicines and Healthcare Products Regulatory Agency  
Medicines & Healthcare products Regulatory Agency 
(MHRA) 

 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Annex III: Survey design 

Survey - Study on corruption in the health sector II  

Welcome to the survey on corruption in the health sector in the European Union. This 
survey is part of the update of the study on corruption in the health sector, 
commissioned by the European Commission Directorate General Migration and Home 
Affairs (DG Home). Please find the introduction letter from the Commission’s DG HOME 
here. 

Corruption is defined as “the abuse of power for private gain” – this is a wide 
definition that also encompasses aspects that go beyond the criminal law aspects, 
including situations such as conflict of interest, favouritism, etc. 

Completion of the survey will take approximately 15 minutes as most of the questions 
only require you to tick a box. 

Confidentiality 

Ecorys Nederland BV adheres to the EU’s legislation on the protection of personal data 
(Regulation (EC) 45/2001). Any data collected through this survey will be managed in 
line with these requirements and will not be shared with third parties. The survey results 
will thereto be stored in a confidential manner. 

The data collected will be aggregated and presented anonymously in the report. It will be 
guaranteed that individual answers will not be traceable to the organisations approached. 

Please inform us should your organisation policy require additional safeguards with 
regard to compliance. We would be pleased to cooperate on this matter. 

If you have any question related to this survey, please contact us via: 
healthsectorstudy@ecorys.com.  

167 

 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Part 1: General information 

In what capacity are you completing this questionnaire? 

Question 
Name 
Organisation  
Function/position 
Country (countries) representing  

Answer  

  Austria  
  Belgium 
  Bulgaria 
  Croatia 
  Cyprus 
  Czech Republic 
  Denmark  
  Estonia 
Finland  
 
France 
 
  Germany  
  Greece 
  Hungary 

 
 

Ireland 
Italy 

Latvia 
Lithuania 
Luxembourg 

 
 
 
  Malta 
  Netherlands 
Poland  
 
Portugal  
 
  Romania  
  Slovakia  
  Slovenia  
  Spain 
  Sweden 
  United 

Kingdom 
  EU in general 

Please indicate the stakeholder category that you are representing  

Sector 
Patient 
Payer 
Provider 
Industry – medical devices 
Industry – pharmaceuticals 
Regulator – medical devices 
Regulator – pharmaceuticals 
Other, please specify: 

Please select one category 
o 
o  
o  
o 
o 
o 
o 
o 

168 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Part  2:  Developments  since  the  publication  of  the  corruption  in  the  healthcare 
study (2013) 

General conclusions of the 2013 report 
Below we provide the general conclusions of the 2013 Corruption in the 
Healthcare study. Indicate for each statement to what extent this is (still) 
applicable to the country or countries you represent.  
Convictions of (high-profile) corruption cases have a deterrent and norm-setting effect 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

Centralisation of procurement is a method to lower the risks of corruption 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

Central procurement systems can become vulnerable as target for lobbyist and more 
political inspired types of corruption 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Bribery in medical service delivery cannot be contested with targeted policies against the 
phenomenon as such  
  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

Raising salaries do not have significant preventive effect on bribery in medical service 
delivery 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

The root causes of corruption in healthcare are related to 
 
 
 
 

Ineffective managerial structures 
Yes / No / To some extent / Do not know 
Inappropriate financing mechanisms   Yes / No / To some extent / Do not know 
Insufficient healthcare capacity  
Yes / No / To some extent / Do not know 
Insufficient funding for independent medical research Yes / No / To some extent / Do 
not know 

  Unequal allocation of resources  
  A general acceptance of corruption in society  Yes / No / To some extent / Do not 

Yes / No / To some extent / Do not know 

know 

  Other root causes, please clarify  

170 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

The introduction of transparent waiting lists has a positive effect on healthcare bribery 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

Prescription of generics instead of branded pharmaceutical products has a positive effect 
on healthcare bribery 
  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

Self-regulation between the industry and healthcare providers is needed to fight 
corruption in healthcare 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Self-regulation among players (such as within the pharmaceutical industry or among 
doctors) is needed to fight corruption in healthcare 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

Awareness raising campaigns and fraud and corruption reporting hotlines are an effective 
instrument to fight corruption in healthcare 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

The government should play a (more) active role in creating transparency in the relations 
between the industry and healthcare providers. 

  Yes 
  No 
  To some extent 
  Not applicable 

Please clarify 

172 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

The importance of active – independent – media involvement and pressure form ‘civil 
society’ watchdogs is essential to fight corruption in healthcare. 

  Yes 
  No 
  To some extent 
  Do not know 

Please clarify 

 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Legislative and policy changes since 2013  

Have there been any relevant legislative developments since 2013 that you are aware of 
in the EU or specific countries? 

  Yes 
  No 
  Do not know 

If yes, could you please briefly describe them or provide links to relevant 
websites/documents? 

Have there been any relevant national policy developments (either anti-corruption 
policies, healthcare sector policies, or anti-corruption-in-healthcare policies) since 2013? 

  Yes 
  No 
  Do not know 

If yes, could you please briefly describe them, specifying the country/countries? 

174 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Part 3: Selected issues 

Issue 1: Informal payments in medical service delivery 

Do ‘informal payments’ frequently occur in your country? 

  All the time; 
  Often; 
  Sometimes; 
  Occasionally; 
  Never; 
  Do not know. 

Has the occurrence of ‘informal payments’ changed since 2013?  

  Yes, it increased; 
  Yes, it decreased; 
  No, it remained the same; 
  Do not know. 

Could you please clarify why this is the case? 

Are you aware of specific policies and practices to prevent and control regarding ‘informal 
payments’ in your country? 

  Yes; 
  No. 

If yes, could you please briefly describe them? 

Are you aware of any recent cases of corruption in healthcare in your country? 

  Yes; 
  No. 

If yes, could you please briefly describe them (including e.g. main actors, whether or not 
it was proven in a court or rather a suspicion of fraud, and links to relevant sources)? 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Issue 2: Corruption in certification and procurement of medical devices 

Does corruption in certification and procurement of medical devices frequently occur in 
your country? 

  All the time; 
  Often; 
  Sometimes; 
  Occasionally; 
  Never; 
  Do not know. 

Has the occurrence of corruption in procurement and certification of medical devices 
changed since 2013?  

  Yes, it increased 
  Yes, it decreased  
  No, it remained the same  
  Do not know  

Could you please briefly why this is the case? 

Are you aware of specific policies and practices to prevent and control regarding 
corruption in procurement and certification in medical devices in your country? 

  Yes 
  No 

If yes, could you please briefly describe them? 

Are you aware of any recent cases of corruption in healthcare in your country? 

  Yes 
  No 

If yes, could you please briefly describe them (including e.g. main actors, whether or not 
it was proven in a court or rather a suspicion of fraud, and links to relevant sources)? 

176 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Issue 3: Corruption in authorisation and procurement of pharmaceuticals 

Does corruption in authorisation and procurement of pharmaceuticals frequently occur in 
your country? 

  All the time  
  Often  
  Sometimes 
  Occasionally 
  Never  
  Do not know 

Has the occurrence of corruption in authorisation and procurement of pharmaceuticals 
changed since 2013?  

  Yes, it increased 
  Yes, it decreased  
  No, it remained the same  
  Do not know  

Could you please clarify why this is the case? 

Are you aware of specific policies and practices to prevent and control regarding 
corruption in authorisation and procurement of pharmaceuticals in your country? 

  Yes 
  No 

If yes, could you please briefly describe them? 

Are you aware of any recent cases of corruption in healthcare in your country? 

  Yes 
  No 

If yes, could you please briefly describe them (including e.g. main actors, whether or not 
it was proven in a court or rather a suspicion of fraud, and links to relevant sources)? 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Issue  4:  Privileged  access  to  medical  services  (including  not  only  informal 
payments but also the use of privileged information and information peddling) 

Privileged access is defined as ''If opportunities of access to medical services are skewed 
in favour of a few privileged persons, which leads to unfair advantage of these persons.'' 
Does privileged access to medical services frequently occur in your country? 

  All the time; 
  Often; 
  Sometimes; 
  Occasionally; 
  Never; 
  Do not know. 

Are you aware of specific policies and practices to prevent and control privileged access 
to medical services in your country? 

  Yes; 
  No. 

If yes, could you please briefly describe them? 

Are you aware of any recent cases of corruption in healthcare in your country? 

  Yes; 
  No. 

If yes, could you please briefly describe them (including e.g. main actors, whether or not 
it was proven in a court or rather a suspicion of fraud, and links to relevant sources)? 

178 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Issue  5:  Improper  marketing  at  pharmaceutical  companies  and  medical  device 
producers  (at  national  and/or  EU  level,  including  for  market  authorisation  and 
reimbursement approval) 

Does improper marketing frequently occur in your country? 

  All the time; 
  Often; 
  Sometimes; 
  Occasionally; 
  Never; 
  Do not know. 

Are you aware of specific policies and practices to prevent and control improper 
marketing in your country? 

  Yes; 
  No. 

If yes, could you please briefly describe them? 

Are you aware of any recent cases of corruption in healthcare in your country? 

  Yes 
  No 

If yes, could you please briefly describe them (including e.g. main actors, whether or not 
it was proven in a court or rather a suspicion of fraud, and links to relevant sources)? 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Issue  6:  Potential  risks  of practising  in both  public  and  private  clinics  (double 
practice) 

Does double practice in public and private clinics frequently occur in your country? 

  All the time; 
  Often; 
  Sometimes; 
  Occasionally; 
  Never; 
  Do not know. 

Are you aware of specific policies and practices to prevent and control double practice in 
public and private clinics in your country? 

  Yes; 
  No. 

If yes, could you please briefly describe them? 

Are you aware of any recent cases of corruption in healthcare in your country? 

  Yes 
  No 

If yes, could you please briefly describe them (including e.g. main actors, whether or not 
it was proven in a court or rather a suspicion of fraud, and links to relevant sources)? 

180 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Part IV: Thank you 

Do you have any other remarks, wishes or thoughts that you would like to share? 

Thank you for your time and contribution to our study. 

 
 
 
 
 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Annex IV: Corruption indicators (Special Eurobarometer 397) 

Table AIV.1 Corruption indicators from Eurobarometer 397, 2014 

QB7 

QB5 

QB5 

QB5 

QB2 

QB3 

QB3 

Corruption in 
health = 
widespread 

Corruption general 
= 
very widespread 

Corruption general 
= 
fairly widespread 

Corruption general  
(TOTAL) 

Bribe paid: 
yes + refusal 

Asked for private  
consultation 

Paid for privileged  
treatment 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czech Rep 

Denmark 

Estonia 

EU-27 

Finland 

France 

Germany 

Greece 

Hungary 

Ireland 

Italy 

Latvia 

Lithuania 

Luxembourg 

Malta 

Netherlands 

15 

15 

55 

56 

62 

41 

12 

30 

33 

4 

24 

30 

81 

56 

15 

44 

53 

74 

15 

18 

27 

13 

19 

41 

54 

29 

61 

4 

15 

35 

2 

19 

16 

67 

36 

40 

58 

38 

58 

9 

44 

19 

53 

48 

43 

40 

49 

34 

16 

50 

41 

27 

49 

43 

32 

53 

41 

39 

45 

37 

33 

39 

42 

4 

2 

9 

3 

2 

5 

1 

3 

5 

1 

5 

8 

12 

12 

3 

5 

8 

23 

2 

2 

1 

66 

67 

84 

94 

78 

95 

20 

65 

76 

29 

68 

59 

99 

89 

81 

97 

83 

95 

42 

83 

61 

183 

28 

10 

7 

15 

0 

0 

23 

17 

12 

0 

20 

10 

10 

11 

36 

8 

7 

8 

0 

67 

12 

2 

9 

11 

0 

0 

24 

23 

10 

19 

0 

29 

29 

16 

9 

4 

13 

7 

4 

0 

23 

0 

 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

QB7 

QB5 

QB5 

QB5 

QB2 

QB3 

QB3 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

UK 

53 

33 

67 

64 

41 

23 

9 

15 

32 

55 

54 

46 

65 

65 

7 

26 

50 

35 

39 

44 

26 

30 

37 

38 

82 

90 

93 

90 

91 

95 

44 

64 

3 

3 

32 

10 

4 

1 

1 

1 

4 

0 

19 

6 

3 

31 

10 

0 

14 

15 

7 

41 

38 

29 

29 

3 

184 

 
 
 
 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

Table AIV.2 Corruption indicators from Eurobarometer 397, 2014 – questions  

References 
T11 
QB5 

QB7 

T18 

QB2 

QB3 

QB3 

T2 

T5 

T5 

How widespread do you think the problem of corruption is in (OUR COUNTRY)? 

In (OUR COUNTRY), do you think that the giving and taking of bribes and the abuse of power for personal gain are widespread among any of the 
following [healthcare]?  

Apart from official fees did you have to give an extra payment or a valuable gift to a nurse or a doctor, or make a donation to the hospital? 

You were asked to go for a private consultation in order to be treated in a public hospital  

You were asked to pay for a privileged treatment  

 
 
 
 
 
Updated Study on Corruption in the Healthcare Sector  

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doi:10.2837/68580 
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