ISLAMABAD: A new study has found widespread deviations from World Health Organisation (WHO) prescribing standards across Pakistan, with doctors prescribing more than twice the recommended number of medicines per prescription, while generic prescribing remains far below the international target.
Patients in Pakistan receive an average of 4.2 medicines per prescription, compared with the WHO-recommended range of 1.6 to 1.8 medicines, according to the study conducted by researchers at the Health Services Academy (HSA), Islamabad.
The research, published in Discover Public Health, reviewed 15 studies examining prescribing practices at hospitals and healthcare facilities in Punjab, Khyber Pakhtunkhwa, Sindh, Balochistan and Islamabad between 2013 and 2024.
The researchers assessed prescribing patterns against WHO indicators, including the number of medicines prescribed per encounter, use of generic names, antibiotic prescribing, use of injections and prescribing of medicines listed as essential drugs. The findings showed that polypharmacy – the prescribing of multiple medicines to a patient – was widespread across the healthcare system.
In one tertiary-care hospital in Peshawar, the average number of medicines prescribed per encounter reached 10.56, almost six times the WHO-recommended level. Even the lowest average recorded among the 15 studies, from an emergency department in Bahawalpur, exceeded the WHO benchmark.
Generic prescribing remains low
The study also found a major gap in the use of generic names. Only around 25 per cent of medicines were prescribed by their generic names, against the WHO target of 100 per cent. In some hospitals, generic prescribing was found to be close to zero, while only two of the 15 studies reported generic prescribing rates above 50 per cent.
Researchers said the low use of generic medicines could increase costs for patients and may be influenced by pharmaceutical marketing as well as perceptions among doctors and patients that branded medicines are more effective.
Prof Shahzad Ali Khan, Vice Chancellor of the Health Services Academy and one of the study’s authors, said the problem was not confined to a particular hospital, city or level of healthcare.
“This is not the problem of one hospital or one city. It is happening across the country, at every level of healthcare,” Prof Khan said. He attributed part of the prescribing pattern to pressure from patients, particularly in relation to antibiotics and injections.
According to Prof Khan, many patients believe that an injection or antibiotic will provide faster relief, while doctors working under pressure and with limited consultation time may sometimes comply with such demands. “Patients think an injection or an antibiotic will cure them quickly. Doctors, under pressure and short of time, often give in,” he said.
Excessive antibiotic use
Antibiotics were found in 45 per cent of prescriptions on average, substantially higher than the WHO benchmark of 20 to 26.8 per cent. The finding is particularly significant amid growing concerns over antimicrobial resistance (AMR) in Pakistan, as inappropriate and excessive use of antibiotics contributes to the development of drug-resistant infections.
READ ALSO: Pakistan Grants Registration Relief to Pre-2023 Postgraduate Doctors
Injections were prescribed in more than 27 per cent of encounters, also exceeding the WHO range of 13.4 to 24.1 per cent. However, the use of injections varied considerably between healthcare facilities, ranging from zero to as high as 98 per cent in some settings. The study further found that only 72 per cent of prescribed medicines were from Pakistan’s essential medicines list, compared with the ideal target of 100 per cent.
AMR adds to health concerns
The findings come amid heightened concern over antimicrobial resistance in Pakistan. Federal health authorities have warned that antimicrobial resistance involving priority bacteria and fungi could result in more than 262,000 deaths in Pakistan over the next 25 years.
The country has also prepared a national Priority Pathogen List to help healthcare authorities and hospitals identify drug-resistant infections requiring greater attention. The Drug Regulatory Authority of Pakistan (DRAP) has previously directed that antibiotics should only be sold against prescriptions issued by registered doctors.
The move followed concerns over the country’s high consumption of antibiotics. Earlier data showed that antibiotics worth around Rs135 billion were consumed in a single year, with an estimated 70 to 80 per cent being used for illnesses that did not require antibiotic treatment.
Weak enforcement of prescribing guidelines
Prof Khan said Pakistan already had prescribing guidelines and policies, but their implementation remained weak. “The problem is not a lack of policy. The problem is that the policy is never followed on the ground,” he said.
The researchers recommended regular monitoring and auditing of prescriptions, along with feedback to doctors about their prescribing practices. They also called for action against healthcare professionals who repeatedly fail to comply with established prescribing standards.
The study urged the government, pharmaceutical industry, hospitals, doctors’ associations and other stakeholders to work jointly to improve prescribing practices. Prof Khan said the health ministry, provincial health departments and the medical profession needed to take coordinated action to address the problem.
“Until this happens, patients will keep taking more medicines than they need, and antibiotics will keep losing their effect against disease,” he said. The researchers said improving prescribing practices would not only help reduce unnecessary medication and healthcare costs but also play an important role in containing antimicrobial resistance and protecting the effectiveness of existing antibiotics.
