It’s possible that such a phenomenon (existence of paper-mills) could be caused by systemic flaws in policy making (in health care system in this case). As it’s

It’s possible that such a phenomenon (existence of paper-mills) could be caused by systemic flaws in policy making (in health care system in this case). As it’s mentioned in the article, such strategies are observed to be adopted by some in Iran and Russia. IMO attributing it to the “culture” of the people in those counties based on the facts presented in the article is far-fetched.