he patient-doctor relationship and health literacy are closely linked. A well informed doctor can equip their patients with evidence-based information that promotes patients’ understanding of their condition and how to manage it effectively. Medication management is an important component of physician’s consultation. It includes both appropriate prescribing and de-prescribing of medication.

Some conditions require short term medication, for example, antimicrobials; others require long-term use, for example, high blood pressure, diabetes, heart failure etc. Appropriate prescribing includes selecting the right medication for the condition keeping in view the patient’s preference (shared decision-making), its previous use, side effects or interaction with his/ her regular medications. Such prescribing is generally achieved through prescribing physician’s awareness of guidelines, physician’s communication skills, presence of co-morbid conditions like liver or renal problems and ability to obtain adequate history from patient. Selecting the right dose, frequency, mode of delivery (e.g. oral, parenteral etc) and duration of medication are also important components of medication prescribing. De-prescribing includes reducing dose or stopping medication. For better treatment outcomes and patient safety, dedicated sessions for medication management need to be incorporated in the healthcare curriculum.

Pakistan’s healthcare system currently lacks a robust primary care system. Prescribing, particularly antimicrobials, can be challenging for practicing physicians due to a number of reasons in particular availability issues. This problem is further exacerbated by hospital policies that restrict prescribing to internal pharmacies and aggressive pharmaceutical company marketing. Clinicians are sometimes faced with a dilemma where they are being forced to choose between administrative rules and proper patient care. Are they undermining medical ethics and fuelling the country’s growing antimicrobial resistance problem?

Hospital formulary systems have a rich history of success when properly implemented. Pioneered in the United States Veterans’ Administration hospitals during the 1950s, these policies spread internationally in the following decades. Sri Lanka’s groundbreaking national pharmaceutical policy in the 1970s, demonstrated that state buying agencies linked to national formularies could dramatically reduce drug costs while maintaining quality. The Sri Lankan model then became a template for developing countries worldwide.

Today, most developed healthcare systems use some form of formulary management. France has successfully implemented hospital formularies alongside its social security system. The UK, Sweden and Australia have established national or regional formularies that balance cost control with clinical effectiveness. Research has consistently shown that well-managed formularies can improve quality of care by carefully evaluating medications for appropriateness, safety and cost-effectiveness.

In Pakistan, a troubling contradiction has arisen between these proven benefits and patient care. Doctors report being pressured to prescribe only medications available in hospital pharmacies, even when clinically superior treatments are available elsewhere. This issue becomes more pronounced when hospital pharmacies are closed. The fundamental problem lies in chronic underfunding—Pakistan’s public hospitals operate with just 22 per cent of their budget available for medicines, far below the WHO’s recommended minimum. This transforms potentially beneficial policies into barriers to optimal medical care.

The situation is made worse by widespread pharmaceutical industry manipulation of prescribing decisions. A major study published this year in BMJ Global Health exposed the shocking extent of this corruption. Researchers found that over 40 percent of Pakistani doctors readily agreed to prescribe specific medications in exchange for cash payments, medical equipment and sponsored travel.

The study’s most disturbing finding was that even targeted education about ethical prescribing failed to change behaviour. More than 30 per cent of doctors who received special training on prescription ethics still accepted pharmaceutical incentives. This shows how deeply embedded these corrupt practices have become in Pakistan’s medical culture.

The results are visible in Pakistan’s prescription patterns. The country has the world’s highest average of 4.4 drugs per prescription. 70 per cent of the patients receive antibiotics whether they need them or not. Generic medicines are almost never prescribed—only 4.3 per cent of prescriptions mention generic names—forcing patients to buy expensive branded drugs.

These failures are devastating for patients and public health. Recent research shows that treating drug-resistant infections costs an extra $34 per patient due to longer hospital stays. For families already struggling with healthcare costs, this represents a crushing financial burden.

Prescription quality has become dangerously poor. Studies reveal that over a quarter of prescriptions are illegible and crucial information is routinely missing. Only 35 per cent include a proper diagnosis and just 25 per cent document medical history. This sloppy practice endangers patient safety and makes proper medical care impossible.

Children face the worst risks. Research from the Punjab found that 97 per cent of hospitalised children receive antibiotics, compared to just 36 percent in developed countries. Nearly half these prescriptions are for powerful broad-spectrum antibiotics that should be reserved for serious resistant infections.

These prescription practices are directly creating Pakistan’s antimicrobial resistance crisis. Hospital studies found that over 70 per cent of patients receive inappropriate antibiotics, with powerful drugs like cephalosporins wrongly prescribed in 67 per cent of cases.

The widespread practice of prescribing antibiotics without proper testing makes the problem worse. In one major study, only four out of sixteen hospitals had facilities to test which antibiotics would actually work against patients’ infections. Without this testing, doctors’ resort to powerful broad-spectrum drugs, accelerating resistance development.

Pakistan needs urgent prescription policy reforms that achieve both administrative efficiency and clinical excellence. The solution is not to abandon institutional medicine management entirely, but to implement it properly with adequate funding and clinical oversight.

Hospital formulary policies could be effective if they included comprehensive medicine options for all common conditions, maintained adequate stock levels through proper funding and established clear exception processes for special clinical needs. The key is ensuring that these systems serve clinical outcomes rather than merely administrative convenience.

First, hospitals need sufficient budgets to maintain comprehensive pharmacy stocks, moving beyond the current 22 per cent of operational funds allocated to medicines. When formularies are properly funded and clinically appropriate, they can achieve cost savings while maintaining care quality.

Second, the government must eliminate rigid restrictions that prevent doctors from prescribing optimal treatments available externally when internal stocks are inadequate or inappropriate. Clear protocols should allow physicians to prescribe outside the formulary when clinically justified, with the hospital system facilitating rather than blocking such decisions.

Third, pharmaceutical company influence must be addressed through strict regulations prohibiting marketing incentives, with mandatory disclosure requirements and real penalties for violations. Patient choice must be restored through generic prescribing mandates, giving families affordable options instead of forcing expensive branded purchases.

Finally, prescription quality standards need urgent enforcement through legibility requirements and complete documentation, whilst antimicrobial stewardship programmes require strengthening with proper laboratory testing to guide antibiotic choices.

Pakistan’s prescription crisis reflects a healthcare system that has lost its way. Current policies force doctors to prescribe from limited hospital stocks while pharmaceutical companies corrupt medical decisions through financial incentives. This violates medical ethics, undermines patient rights, and accelerates drug resistance.

The evidence is overwhelming that fundamental reform is needed. Clinical decisions must be returned to qualified physicians rather than administrators or pharmaceutical sales representatives. Only by putting medical ethics, patient welfare and evidence-based medicine first can Pakistan fix its broken prescription system and tackle the growing threat of drug-resistant infections.

The cost of inaction is too high to ignore. The patients deserve a healthcare system that puts their interests first.

Dr Hina Jawaid is an associate professor in Family Medicine at Health Services Academy, Islamabad.

Dr Tehzeeb Zulfiqar is a research fellow at Australian National University, Canberra.