Factors leading to irrational prescribing amongst general practitioners of Karachi, Pakistan

Date of Award


Document Type


Degree Name

Master of Science in Epidemiology & Biostatistics (MSc Epidemiology & Biostats)


Community Health Sciences


General practitioners constitute the backbone of the health care system of Pakistan. Literature review indicates that expensive nonessential drugs are widely prescribed by these practitioners, leading to wastage of precious resources. To study the extent and determinants of irrational prescribing amongst the general practitioners of Karachi, Pakistan, we conducted a cross sectional survey between July -September 1997. A total of 252 general practitioners with M.B.B.S. or greater qualifications, seeing at least 40 patients daily were interviewed and their prescribing practices observed for 2 tracer diseases i.e. Upper Respiratory Tract Infections (rhinitis, pharyngitis and tonsillitis) and Hypertension. Prescribing information on 2 patients per tracer disease per GP was collected to assess the rationality of prescription. To identify factors leading to irrational drug prescription questionnaires were used. These questionnaires were specifically designed to assess the theoretical knowledge of the practitioners, as well as to look into factors other than knowledge that could lead to irrational prescribing. Our results show that more than 80% of patients suffering from URTI were prescribed an antibiotic and an analgesic, and nearly 50% of them antihistamines and antitussives. More than half of the patients (56%) suffering from hypertension were prescribed a benzodiazepine, and less than 25% of them initiated into therapy with diuretics or beta blockers (the first line recommended drugs). Only 42% of the GP observed prescribed a correct drug in a correct dose, for the correct duration and via the correct route as specified in a locally formulated guideline (based predominantly on WHO recommendations) in at least 2 of their 4 patients evaluated. Multiple logistic regression analysis which controlled for confounding and assessed the impact of individual risk factors on the irrational prescription of drugs revealed that physicians with knowledge scores below 40% were 1.7 times more likely to prescribe irrationally as compared to physicians with higher scores. Similarly physicians with > 15 years of experience were more likely to prescribe irrationally as compared to physician with lesser experience [OR 1.5, CI (1.0, 2.3)]. Non attendance at continuing medical education programs IOR 1,.8, CI (1.2,2.6)1, and possession of minor post graduate qualification (DCH, DLO, Dip Card, DTCD, DTM, DFM) as compared to major post graduate qualification (MCPS, FCPS (1), MRCP(1)) [OR 3.2, CI (L.3,8.2)], were both found to substantially increase the risk of irrational prescribing. In addition competition emerged as a strong determinant of irrational prescribing; physicians faced with competition were found to be 2.4, times more likely to prescribe irrationally as compared to physicians not faced with competition. Our results clearly demonstrate that while inadequacy or obsolescence of knowledge plays an important role in the irrational prescription of drugs. Nonetheless measure directed towards improvement of physician’s knowledge only will not effectively control irrational prescribing. Economic and practice based incentives play an equally important role in initiating and maintaining irrational prescription of drugs. Thus measure to control irrational prescribing should be directed not only towards educating the physician, but also be aimed at educating and thus empowering the patient's.

This document is available in the relevant AKU library