Sale of WHO AWaRe groups antibiotics without a prescription in Pakistan: A simulated client study

Zikria Saleem*, Mohamed Azmi Hassali, Brian Godman, Munazzah Fatima, Zeenia Ahmad, Areeba Sajid, Inaam Ur Rehman, Muhammad Umer Nadeem, Zaida Javaid, Madeeha Malik, Azhar Hussain

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

53 Citations (Scopus)


Introduction: Resistant strains of bacteria are rapidly emerging with increasing inappropriate use of antibiotics rendering them less efficacious. Self-purchasing of antibiotics particularly for viral infections is a key driver of inappropriate use, especially in lower- and middle-income countries. There is a particular issue in countries such as Pakistan. Consequently, there is a need to assess current rates of self-purchasing especially for reserve antibiotics to guide future policies. Aims: Assess the extent of current antibiotic sales without a prescription in urban areas of Pakistan. Methodology: A multicenter cross-sectional study was conducted in different areas of Punjab, Pakistan using Simulated Client technique. The investigators demanded different predefined antibiotics from WHO AWaRe groups without prescription. Three levels of demand were used to convince the pharmacy staff in order to dispense the antibiotic without a prescription. A data collection form was completed by simulated clients within 15 min of each visit. Results: Overall 353 pharmacies and medical stores were visited out of which 96.9% pharmacies and medical stores dispensed antibiotics without demanding a prescription (82.7% at demand level 1 and 14.2% at demand level 2), with only 3.1% of pharmacies refusing to dispense antibiotics. The most frequently dispensed antibiotic was ciprofloxacin (22.1%). Surprisingly, even the reserve group antibiotics were also dispensed without a prescription. In only 25.2% visits, pharmacy staff guided patients about the use of antibiotics, and in only 11.0% pharmacists enquired about other medication history. Conclusion: Currently, antibiotics are easily acquired without a legitimate prescription in Pakistan. There is a need for strict adherence to regulations combined with a multi-dimensional approach to enhance appropriate dispensing of antibiotics and limit any dispensing of WHO restricted antibiotics without a prescription.

Original languageEnglish
Article number26
JournalJournal of Pharmaceutical Policy and Practice
Issue number1
Publication statusPublished - 3 Aug 2020
Externally publishedYes


  • Antibiotics
  • Pakistan
  • Sale without prescription
  • Simulated client


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