Latin American Journal of Pharmacy Short Communication

(formerly Acta Farmacéutica Bonaerense) Received: December 31, 2012

Revised version: June 18, 2013
Lat. Am. J. Pharm. 32 (7): 1098-1101 (2013) Accepted: June 20, 2013

Assessment of Prescribing Practices of Prescribers in Abbottabad,

Pakistan, using WHO Guidelines
Hanif ULLAH 1, Ghulam MURTAZA *1, Kashif BASHIR 1, Aqeel IMRAN 1, Ossam CHOHAN 2,
Muhammad SHER 3, Muhammad R. AKRAM 4, Sabiha KARIM 5 & Syed M.A. ABID 1

Department of Pharmaceutical Sciences & 2 Department of Mathematics,

1

COMSATS Institute of Information Technology, Abbottabad, Pakistan

3 Department of Chemistry & 4 Department of Pharmacy, University of Sargodha, Sargodha, Pakistan
5 University College of Pharmacy, University of the Punjab, Lahore, Pakistan

SUMMARY. The objective of this study is to assess and compare prescribing practices of Public and Pri-
vate Prescribers of Abbottabad, Pakistan. A comparative cross-sectional study for evaluating the prescrib-
ing practices of private and public healthcare practitioners. WHO Prescribing Indicator Form was used to
collect the data and study the prescribing practices. Overall the average number of drugs per prescription
was 4.10 ± 1.505. Percentage of antibiotics prescribed was 17.78%. Percentage of drugs prescribed by
generic name was 0.13%, 68.72% of drugs prescribed were from Essential Drug List. Multivitamins pre-
scribed were 7.51% and percentage of injections was 6.87%. The average number of drugs per prescrip-
tion was not significantly different between the prescription of public sector and private sector of Abbot-
tabad i.e. 3.97 drugs for public and 4.24 drugs for private sector. Overuse of antibiotics was low in present
study as compared to the studies conducted in India (58%), China (48.43%) and United Arab Emirates
(31.10%). The prescribing practices are not being properly followed according to WHO guideline, yet in
case of some indicators like percentage of antibiotics prescribed and percentage of injections prescribed
was lower than other countries.

INTRODUCTION World Health Organization (WHO) indicators

Rational drug use requires that patients re-
ceive medications appropriate to their clinical
needs, in doses that meet their own individual
requirements, for an adequate period of time,
and at the lowest cost to them and their com-
munity 1. These conditions can only be fulfilled
if the prescribing practices are rational and ap-
propriate. The words rational and appropriate
are being used interchangeably. In general the
rational drug use is based on correct diagnosis,
correct drug, correct dose, correct frequency,
and correct use of that drug for a right person 2.
Studies carried out to investigate drug use pat-
terns indicate that overprescribing, polypharma-
cy, misuse of drugs, use of unnecessary costly
drugs and overuse of antibiotics and injections
are the most common examples problems of ir-
rational drug use by prescribers as well as con-
sumers 3.
are used to measure three major parts of the
drug use process including prescribing indica-
tors. A study was conducted in twelve develop-
ing countries to evaluate the rational drug use
by employing drug use indicators in order to
create awareness among prescribers and to
identify the factors that are involved in the hin-
drance of rational drug use like polypharmacy,
overuse of injections and lack of knowledge
among patients regarding the use of medicine 4.
A study conducted on the use of injections in
Asian and Western countries highlighted that
overuse of injections and unsafe practices were
more common in Asian countries 5 . In another
study conducted in West Bengal, India, for ratio-
nal drug use reported that polypharmacy and
overuse of antibiotics were major problems 6.
Rational prescribing is the major goal for the
benefit of the patients. Rational drug use helps

KEY WORDS: Prescribing indicators, Prescribing practices, Rational drug use, WHO guidelines.
* Author to whom correspondence should be addressed. E-mail: gmdogar356@gmail.com

ISSN 0326-2383 1098

ULLAH H., MURTAZA G., BASHIR K., IMRAN A., CHOHAN O., SHER M., AKRAM M.R., KARIM S. & ABID S.M.A.
to satisfy the patient to develop a deeper and
longer relationship with their medical providers,
leading to improved compliance, and ultimately
better outcomes 7. Irrational prescribing ulti-
mately results in irrational drug use by the pa-
tient due to various reasons. A few of them in-
clude drug prescribed without a medical prob-
lem, use of two or more drugs without consid-
ering their interactions, multiple prescriber for
the same patient, and polypharmacy. A study
was conducted in south west Ethiopia in four
facilities, out of which two had the copy of Es-
sential Drug List (EDL), only one facility had the
copy of formulary. The pattern of prescription
in terms of generic name and Polypharmacy
was near to optimal. Antibiotics and injections
are appropriately used 8.
A study conducted in India to assess the ra-
tionality of drug use and it was concluded that
average number of drugs were higher, generic
prescriptions were lower and drugs prescribed
from EDL were low. So it is necessary to im-
prove prescriber’s behavior in order to improve
rational drug use 9.
Prescribing practices have also been studied
in Pakistan. Studies conducted in Pakistan on
the rational use of medicinal drugs suggested
that for improving the present situation, particu-
lar attention should be given to the selection,
availability and rational use of essential drugs,
education of doctors, physicians, pharmacist,
the dissemination of drug information, prescrib-
ing practices 10. A study reported in health care
center of Bahrain conducted to assess prescrib-
ing practices highlighted that number of antibi-
otics prescribed were higher than the injections
and these were due to polypharmacy and not
prescribing by generic names 11. According to
different studies in Pakistan these irrational pre-
scribing practices result in increased cost of
treatment, morbidity and antibiotic resistance. Ir-
rational drug use cannot only be attributed to
the prescriber only but also to the patient. Self-
medication by the patient may also leads to
non-adherence of the patient. Pricing policies
and drug promotional activities also affect pa-
tient compliance and the dosage regimen 12,13.
The objective of this study is to assess and
compare prescribing practices of Public and Pri-
vate Prescribers of Abbottabad. This study will
provide a baseline data to overview the current
rational drug use and will give an insight about
the current prescribing practices and dispensing
practices. It will also help the policy makers to
1099
improve health care system and identifying the
difference factors involved in irrational drug use.
METHODOLOGY
A comparative cross sectional study was de-
signed to assess prescribing practices at health
care facility in public and private sectors of Ab-
bottabad, Pakistan. Study was conducted at Out-
door Patient Department (OPD) of above men-
tioned facilities of Abbottabad. The respondents
were doctors, patients and dispensers. The dis-
ease included were Acute Respiratory Tract In-
fection (ARI), fever, flue, cough, Diarrhea,
headache. For prescribing indicators, 200 ques-
tionnaires were filled from both health facilities
(public = 100, private = 100). Convenient sam-
pling method was used to conduct this study.
WHO Prescribing Indicator Form was used for
designing and collection of data questions. This
was modified according to the objective of our
study by discussing with the experts.
The prescribing indicators used for conduct-
ing this study help to measure the contributions
of the medical practitioners in practicing rational
drug use. The detailed prescribing indicators
were used to evaluate and analyze the prescrib-
ing patterns. The combination of two or more
drugs in a pharmaceutical product was counted
as a single drug. The average number of drugs
prescribed, percentage of drugs prescribed by
generic name, percentage of antibiotics pre-
scribed and percentage of injections was calcu-
lated. Adherence to EDL was also estimated by
calculating the percentage of drugs prescribed
from EDL.
Statistics
After data collection, data was coded double
entered and analyzed by using Statistical Pack-
age for the Social Sciences (SPSS) version 19.0.
The level of significance was kept at 0.05.
RESULTS AND DISCUSSION
A total of 200 prescribers were involved in
this study. The demographic data of prescribers
are shown in Table 1. The mean age of pre-
scribers was 33.34 ± 5.12. Out of these, 94.24%
were males and 5.76% were female practition-
ers. Mean experience of prescribers was 9.38 ±
2.44.
Overall, the average number of drugs was
4.10 ± 1.51 (3.97 ± 0.10 for public health facility
as compared to 4.24 ± 0.18 for private health
sector facility). The percentage of antibiotics
 Latin American Journal of Pharmacy - 32 (7) - 2013

In our study, drug prescribed by generic

Age (Mean ± SD) 33.34 ± 5.12
Gender
Male (%) 94.24
Female (%) 5.76
Years of experience (Mean ± SD) 9.38 ± 2.44
Designation
GPs 100
Consultants 100
Table 1. Demographic data of prescribers (n = 200).
prescribed per encounter was 41.50% (40% for
prescribers in public facility, 43% for prescribers
in private facility. Percentage of drugs pre-
scribed by generic name was 0.13% (0.25% for
public and 0.00% for private sector). The drug
prescribed from EDL was 68.72% (74.00% in
public sector and 63.44% in private sector). The
Injections prescribed were 6.87% (1.01% in pub-
lic healthcare facility and 12.73% in private facil-
ity) as illustrated in Table 2.
The different prescribing indicators assessed
in this study provide an insight into the pre-
scribing behavior of the public and private sec-
tor practitioners in Abbottabad, Pakistan. The
average number of drugs per prescription was
not significantly different between the prescrip-
tion of public sector and private sector of Ab-
bottabad, i.e. 3.97 drugs for public and 4.24
drugs for private sector. Use of generic names in
prescription eliminate the chance of duplication
of drug products and also reduce the cost of the
patient.
name was negligible as no drug was prescribed
by generic name and only one drug was pre-
scribed by generic name in public sector and
there was no significant difference in the per-
centage of the drug prescribed by generic name
between the two sectors. Percentage of generic
prescription was lower as compared to a similar
study conducted by Vijayakumar and colleagues
in India (76%) as mentioned in Table 3 9 .
Generic prescription was also higher in China
(64.12%) and United Arab Emirates (UAE,
7.35%) as shown in Table 3. The regulatory
bodies should make it mandatory that drugs
should be prescribed by generic name in order
to ensure rational drug use as rational prescrib-
ing will provide less expensive alternate and
will help pharmacy stakeholder to keep a more
limited inventory of drugs 14.
It was observed that overuse of antibiotics
was low in present study as compared to the
studies conducted in India (58%), China
(48.43%) and UAE (31.10%) as depicted in Table
3. There was non-significant (p > 0.05) differ-
ence in the percentage of antibiotics prescribed
between two facilities of Abbottabad. In the pre-
sent study the number of drugs prescribed from
EDL was high, but there was non-significant (p
> 0.05) difference among two groups. Similar
study was conducted in UAE reported that ad-
herence to EDL was low 14 as there is no con-
cept to adherence to EDL in Pakistan. Higher
use of antibiotics is one of major irrational drug

Facilities p-value
Prescribing indicator Total
Public sector Private
(n = 100) (n = 100)

Number of drugs per prescription (Mean ± SD) 4.10 ± 1.50 3.97 ± 1.04 4.24 ± 1.85 NS
Antibiotics prescribed (%) 17.78 15.28 20.28 NS
Prescribing by generics (%) 0.126 0.25 0.00 NS
EDL followed (%) 68.72 74.00 63.44 NS
Multivitamins (%) 7.51 10.32 4.71 NS
Injections (%) 6.87 1.01 12.73 0.001
Table 2. Prescribing practices of public and private practitioners. NS stands for non-significant.

Prescribing Indicator Pakistan China UAE India

Number of drugs per prescription (Mean) 4.10 2.36 2.9 3.3

Antibiotics prescribed (%) 17.78 48.43 31.1 58
Prescribing by generics (%) 0.126 64.12 7.35 76
EDL followed (%) 68.72 67.70 64 98.6
Injections (%) 6.87 22.93 2.9 4.3
Table 3. Comparison of prescribing indicators with other countries.

1100
ULLAH H., MURTAZA G., BASHIR K., IMRAN A., CHOHAN O., SHER M., AKRAM M.R., KARIM S. & ABID S.M.A.
use problems and suitable interventions should
be taken to surmount the problem 14.
Furthermore, in our study, use of injection in
private facility was significantly higher than that
prescribed in public facility (p = 0.001). The
possible reason of higher injection prescribing
among the private practitioners can be due to
the reason that patient can recover from the dis-
ease faster and the physicians think that they
will lose their patient if don’t prescribe injection
to them. While the overall use of percentage of
injections was significantly higher between two
sectors which is lower than that of Western Chi-
na (22.93%) 15.
The availability of EDL and formulary leads
to the rational drug use. A study conducted in
South West Ethiopia revealed that EDL and for-
mulary was available in most of the facilities 8.
In present study no copy of EDL was present in
both facilities. However, copy of formulary was
present in public sector facility.
Over prescription of the multivitamin is also
a common practice. In our study, percentage of
multivitamins prescribed is higher in public sec-
tor and less in private sector.
The results of our study were also compared
with the prescribing indicator of China, UAE
and India. Average number of drugs prescribed
in Pakistan was high in Pakistan as compared to
these three countries. Antibiotics prescribed
were less in Pakistan. Generic prescribing was
very much less in Pakistan. EDL followed was
higher in India and was almost similar in Pak-
istan, UAE and China. Injections in Pakistan
were prescribed less as compared to China but
more than UAE and India. The limitations of this
study include small sample size as well the se-
lection of this sample from only one city of Pak-
istan.
CONCLUSION
Our study shows that the prescribing prac-
tices are not being properly followed according
to WHO guideline, yet in case of some indica-
tors like percentage of antibiotics prescribed
and percentage of injections prescribed were in
1101
better compliance with WHO guidelines than
studies conducted in other countries. In view of
above findings and discussions it is recommend-
ed that overuse of antibiotics must be controlled
by training the prescriber. Availability and im-
plementation of EDL must be ensured. There
should be proper check and balance of regula-
tory authorities on prescribing patterns to solve
the issues in prescribing practices.
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