International Journal for Quality in Health Care 2005; Volume 17, Number 4: pp. 307–313 10.

1093/intqhc/mzi049
Advance Access Publication: 5 May 2005

Quality of pharmacies in Pakistan:

a cross-sectional survey
ZAHID A. BUTT1, ANWAR H. GILANI2, DEBRA NANAN3, ABDUL L. SHEIKH4 AND FRANK WHITE3
1
World Health Organization, Campaign and Social Mobilization Cell, Islamabad, Punjab, Pakistan, 2Aga Khan University, Biological and
Biomedical Sciences, Karachi, Pakistan, 3Pacific Health and Development Sciences, Victoria, British Columbia, Canada, 4Aga Khan
University, Department of Pharmacy, Karachi, Pakistan

Abstract
Objective. To estimate the proportion of pharmacies meeting licensing requirements and to identify factors associated with
these pharmacies in urban Rawalpindi, Pakistan.
Design. Cross-sectional questionnaire survey conducted during July–September 2001, of 311 pharmacies selected from a drug

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company list of 506.
Setting. Free-standing licensed and unlicensed pharmacies in urban Rawalpindi.
Study participants. A pharmacist or (if unavailable) the most experienced drug seller.
Results. The proportion of pharmacies meeting licensing requirements was 19.3% [95% C.I (confidence interval): 15.1, 24.2],
with few qualified persons (22%). Only 10% had a temperature-monitoring device and 4% an alternative power supply for
refrigerators (present in 76% of pharmacies). Associated with pharmacies meeting licensing requirements was the knowledge
of not giving co-trimoxazole, a prescription drug, without prescription [OR (odds ratio) = 2.0; 95% CI: 1.1, 3.6], knowledge of
the temperature range for vaccines (OR = 2.6; 95% CI: 1.4, 4.8), availability of vaccines (OR = 2.8; 95% CI: 2.8, 18.4), and
alternative power supply for the refrigerator (OR = 6.0; 95% CI: 1.5, 23.7). The practice of selling drugs without prescription
was not found to have a significant association (OR = 1.1; 95% CI: 0.5, 2.3); however, it did show a trend indicating discrepancy
between knowledge and practice.
Conclusions. Most drug sellers had fragmentary knowledge regarding drug dispensing and storage, and improper dispensing
practices. There is a need to enforce existing legislation with training programmes directed towards drug sellers and to involve
the pharmaceutical industry, which plays an important role in influencing pharmacy knowledge and practices.
Keywords: drug sellers, licensing requirements, Pakistan, pharmacies

Drugs and vaccines are important tools in combating diseases
worldwide, but may also cause adverse events, with severity
depending upon patient- and product-specific factors. This
reality is even more important in developing countries where
most medications can be purchased over the counter, includ-
ing those with a high incidence of side effects or adverse reac-
tions [1,2]. When coupled with a greater propensity towards
self-medication, this may have serious consequences for pub-
lic health in developing countries. National data on self-medi-
cation are not available in Pakistan, but local studies reveal
that this may vary between 6.3% and 51.3% depending on the
setting [3,4]. However, self-medication with appropriate guid-
ance can also be beneficial, keeping in mind the limited
resources and health facilities available in developing coun-
tries. In this context the role of pharmacies has broadened,
incorporating not only dispensing, but also health education,
and sometimes even diagnosis.
In the developing world, drug sellers operating in the informal
sector are often the first source of health care, especially in
settings where self-medication is the norm [4]. Reasons cited
by patients include expediency, convenience, efficacy of medi-
cines, dependability of supply, and cost reduction [5]. This
has important implications for the role of drug sellers, more
so for those with no qualifications in pharmacy. Unfortu-
nately many drug sellers tend to recommend medicines with
lucrative profit margins without sufficient concern for the
appropriateness (indications, efficacy, safety) of the drug [6].
A preliminary study conducted in Pakistan reported that
many drug sellers have minimal formal education and little or
no professional training; of those with training, most were
absent from pharmacies [7], a practice also observed in other
developing countries [2,5,8–10]. Given the limited knowledge
of sellers regarding indications, contraindications, and side
effects, their dispensing practices may have undesired effects.

Address reprint requests to Zahid A. Butt, House No:3, Street no:65, Sector:f-7/3, Islamabad, Punjab, Pakistan. E-mail: drzahid
@whopak.org; zabutt3@yahoo.com

International Journal for Quality in Health Care vol. 17 no. 4

© The Author 2005. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 307
Z. A. Butt et al.
Although there is a network of health services in Pakistan’s
public sector, and a plethora of private sector initiatives, 45%
of the population still lacks access to health services [11]. The
physician:population ratio is 57 per 100 000 people as compared
with 85 in Iran or 311 in developed countries like Sweden
[12]. To meet health needs and to reduce personal costs,
people rely on alternative health care systems such as chemists,
traditional medicine practitioners, faith healers, and homeo-
paths. Large gaps in the formal health sector encourage self-
medication; hence the knowledge and practices of drug sellers
becomes critically important in Pakistan.
There are an estimated 45 000–50 000 retail and wholesale
drug outlets in Pakistan (population 145 million). However,
only about 800 individuals per annum graduate as Bachelors
of Pharmacy, which translates to very few qualified personnel
available to staff these outlets. A majority of drug stores,
therefore, have persons with little or no professional training.
The Government of Pakistan (GOP) has established pre-
conditions for issuing a pharmacy licence. The drug laws of
Pakistan [13] require that:
(i) pharmacy premises should have proper and adequate
facilities for drug storage including refrigeration,
(ii) premises be clean and in a hygienic and tidy condition, and
(iii) drug sales should be under continuous personal supervi-
sion of a pharmacist (Pharmacy Act, 1967).
Given that Pakistan has insufficient data on the operation of
pharmacies, this study was undertaken to estimate the
proportion of Rawalpindi pharmacies meeting GOP licensing
requirements, and to identify factors associated with meeting
these requirements
Methods
Rawalpindi (population 3.4 million) is situated 280 kilometres
from Lahore and 173 kilometres from Peshawar. It shares an
international airport, railway and bus stations with Islamabad,
Murree, and Peshawar. There are 16 hospitals and 200 basic
health facilities.
As no GOP list of pharmacies was available, a cross-sectional
survey was conducted in Rawalpindi from July to September
2001, using a list provided by a multinational pharmaceutical
company. The list consisted of all free-standing pharmacies
visited by their representatives (effective 16 May 2001)
including licensed and unlicensed operations. While we can-
not be sure that the list is comprehensive, we believe that it
includes the majority of such facilities in Rawalpindi.
The sampling frame included any outlets in urban
Rawalpindi selling allopathic medicines and homeopathic or
herbal medicines if sold alongside allopathic medicines.
Excluded were pharmacies located on hospital premises or
where a doctor was practising (i.e. private dispensaries), and
those selling only homeopathic or herbal medicines. Any
shop meeting this definition constituted the sampling unit,
the sampling element being the drug seller. A simple random
sample of 310 pharmacies was obtained using a random
number table. From each outlet, a pharmacist with a Bach-
308
elor’s degree or Diploma in Pharmacy was identified [13]. If a
pharmacist was unavailable, the most experienced drug seller
was interviewed, a single respondent thereby being selected
from each outlet.
For the purpose of sample size determination, due to the
paucity of studies on this topic in Pakistan, the proportion of
pharmacies meeting licensing requirements was assumed to
be 50% and, with a population size of 506 (after applying
exclusion criteria), the sample size calculated was 224. For
associated factors, assuming the prevalence of an unqualified
proprietor in pharmacies meeting licensing requirements to
be 29% [2], a sample size of 310 was determined suitable to
meet both study objectives. Ethical approval was obtained
from the Aga Khan University’s Ethical Review Committee.
Training in the use of structured questionnaires was con-
ducted over a 7 day period in early July 2001. Pre-testing was
performed in the second week on 31 questionnaires, or 10%
of the sample size. Formal data collection ran from 15 July to
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30 September involving two data collectors and the principal
investigator. Permission for the study was obtained from the
District Health Officer. Study subjects were briefed and
informed verbal consent obtained. To ensure quality control,
completed questionnaires were screened daily by the principal
investigator. After data collection, data were edited to ensure
quality for data entry.
The questionnaire collected demographic data on the drug
seller’s age, sex, years of formal schooling, professional qualifica-
tion, and years working in a pharmacy. It included fields related
to professional knowledge and practice: sources of current drug
information, whether certain drugs could be sold without pre-
scription, temperature range for vaccines, commonly used termi-
nology, and dispensing practices. Information collected on
pharmacy characteristics included: location, availability of vac-
cines, whether selling drugs exclusively or general goods also, and
presence of an alternative power supply for the refrigerator.
The rationale for this selection of variables was to represent
the person, the product, and the environment, all three of
which were considered equally important to drug and vaccine
efficacy and safety. The condition of the pharmacy floor
(used as a proxy for cleanliness) was assessed by its smooth-
ness and whether it was washable. A pharmacy obtaining the
maximum score of 3 was labelled as meeting licensing
requirements, while a pharmacy obtaining a score of either 0,
1, or 2 was labelled as not meeting requirements.
All data were double-entered in EPI INFO version 6.04
and analysis performed in SPSS version 10.0. Descriptive stat-
istics were generated to ascertain patterns of distribution. For
logistic regression analysis, the outcome variable (‘pharmacies
meeting licensing requirements’) was devised by summing
three variables: presence of a pharmacist, presence of a refrig-
erator, and condition of the floor (adequacy of person, product,
and environment) and are based on the requirements under
the drug laws of Pakistan [13].
In univariate analysis, the unadjusted association of factors
with the outcome variable was evaluated; odds ratios (ORs) and
95% confidence intervals (CIs) were calculated. Appropriate
scales for continuous variables (age, work experience, years of
formal schooling) were assessed through quartile analysis.
 Quality of pharmacies in Pakistan

Multivariable analysis served to assess the association of
factors with pharmacies meeting requirements while adjusting
for confounding effects of other variables. Adjusted ORs
(adjOR) and their 95% CIs were used to interpret the model.
Results
A total of 311 pharmacies was enrolled; interview response
rate was 100%. Out of 311, only 60 (19.3%, 95% CI: 15.1,
24.2) pharmacies situated in urban Rawalpindi met licensing
requirements.
The mean age of drug sellers was 39 years (SD 8.04), nearly
all (99%) males (Table 1). Only 22% were qualified pharmacists;
mean years of formal schooling was 12.6 (SD 1.6). The majority
of drug sellers (71%) obtained their current information
about drugs from industry representatives. The mean years of
work experience of drug sellers was 12.8 (SD 7.0).
Among the most commonly bought antibiotics, quinolones
and cephalosporins comprised the major proportion, followed
by penicillins, co-trimoxazole, and tetracyclines. A large
proportion of drug sellers (64%) thought (incorrectly) that
co-trimoxazole could be dispensed without prescription
(Table 3). Only half (53.7%) had correct knowledge about the
holding temperature for vaccines. Nearly all could interpret
some prescription terminology: OD, BD, and TID; however,
knowledge regarding QID, HS, and SOS was unsatisfactory.
When sellers were asked whether they sold prescription drugs
without prescription, around 16% admitted to this.
Univariate analysis was performed to assess the association
of independent variables with pharmacies meeting licensing
requirements. Pharmacies meeting requirements were more
likely to be situated near a hospital, to have vaccines and an
alternative power supply for the refrigerator (Table 4). These
were also more likely to have drug sellers with: work experience
of 16 years or more, a variety of sources for acquiring current

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About 60% of pharmacies sold only drugs, while the
remaining 40% sold other items as well (Table 2). The major-
ity (76%) had a refrigerator present; however, only 10% of
these had a temperature-monitoring device, and only 4% had
an alternative power supply. Another legal requirement is that
the licence should be displayed openly, but this was visible in
only 6% of pharmacies. In nearly all (97%), the floor was
found to be smooth and washable. The majority (70%) were
located away from a hospital. Vaccines were available in 60%.
drug knowledge other than representatives, knowledge that co-
trimoxazole cannot be given without prescription, knowledge
of the temperature range for vaccines, and knowledge of pre-
scription terminology, than pharmacies not meeting require-
ments. However, the practice of giving drugs without
prescription was not found to have a significant association.
The final logistic regression model included: availability of
vaccines, alternative power supply for the refrigerator,
drug seller’s work experience, knowledge of vaccine storage

Table 1 Distribution of basic characteristics of the drug sellers in pharmacies situated in urban Rawalpindi (n = 311)

Variable Frequency (%)

......................................................................................................................................................................................... .................................

Age (years) mean (SD) 39.1 (7.6)

Sex
Male 308 (99.0)
Female 3 (1.0)
Professional qualification
Pharmaceutical education 6 (1.9)
Bachelor of Pharmacy 63 (20.3)
Diploma in Pharmacy 242 (77.8)
No pharmaceutical education
Years of formal schooling, mean (SD) 12.6(1.6)
Source of current drug knowledge
On the job experience 7 (2.3)
Medical representatives 223 (71.7)
Neighbouring chemist shop 5 (1.6)
Doctor 3 (1.0)
Distributors 4 (1.3)
On the job experience and medical representative 29 (9.3)
Books and medical representative 3 (1.0)
Medical representative and doctor 16 (5.1)
On the job experience and medical representative and doctor 2 (0.6)
Journal articles and medical representative and doctor 1 (0.3)
Not applicable 18 (5.8)
Work experience of the drug seller (years of work in a pharmacy), mean (SD) 12.8 (7.0)

SD, standard deviation.

309
Z. A. Butt et al.

Table 2 Distribution of various factors among pharmacies situated in urban Rawalpindi (n = 311)

Variable Frequency (%)

............................................................................................................................................................................................... ...........................

Exclusive sale of drugs at the pharmacy 185 (59.5)

Licence visible 18 (5.8)
Air conditioner present 15 (4.8)
Refrigerator present1 235 (75.6)
Temperature-monitoring device present 32 (10.3)
Alternative power supply for the refrigerator present 12 (3.9)
Floor of pharmacy smooth and washable1 300 (96.5)
Most commonly bought antibiotics by group
Penicillins 60 (19.3)
Co-trimoxazole 4 (1.3)
Tetracyclines 1 (0.3)
Cephalosporins 117 (37.6)
Fluoroquinolones 121 (38.9)
No response 8 (2.6)

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Vaccines available 185 (59.5)
Location of the pharmacy
Away from hospital 215 (69.1)
Near hospital 96 (30.9)
Operating hours of pharmacy, mean (SD) 13.6 (3.4)
1
Criterion for licensing requirements.

Table 3 Knowledge and practice of drug sellers in pharmacies situated in urban Rawalpindi (n = 311)

Variable Frequency (%)

.........................................................................................................................................................................................................................
1
Knowledge of whether co-trimoxazole could be given without prescription 198 (63.7)
Knowledge of temperature range for vaccines 167 (53.7)
Correct knowledge of prescription terminology
OD 302 (97.1)
BD 297 (95.5)
TID 288 (92.6)
QID 176 (56.6)
HS 105 (33.8)
SOS 97 (31.2)
Practice of giving drugs without prescription 50 (16.1)
1
Can be given without prescription.
OD, once a day; BD, twice a day; TID, three times a day; QID, four times a day; HS, before going to bed; SOS, when required.

temperatures, knowledge that co-trimoxazole requires prescrip-
tion, and the practice of giving drugs without prescription
(Table 4), and was selected on the basis of statistical signifi-
cance and biological plausibility.
After adjusting for the effect of other variables, pharmacies
meeting requirements were more likely to have vaccines available
and an alternative power supply for the refrigerator. Drug
sellers with: work experience 9–11 years, 12–15 years, and 16
or more years, knowledge of temperature range for vaccines,
knowledge that co-trimoxazole should not be given without
prescription were associated with meeting requirements after
adjusting for all other variables; interestingly, they were also
more likely to give drugs without prescription.
Discussion
Only about one-fifth of pharmacies sampled met licensing
requirements. Most had unqualified personnel selling drugs
and providing advice and treatment on common health prob-
lems, while drugs were commonly sold irrespective of
whether the client had a prescription, as documented in other

310
 Quality of pharmacies in Pakistan

Table 4 Univariate and multivariable analysis of different factors associated with pharmacies meeting licensing requirements
in urban Rawalpindi

Variable Pharmacies Pharmacies Crude 95% CI Adjusted 95% CI

meeting not meeting OR for OR OR for adj OR
licensing licensing
requirements requirements
(60), n (%) (251), n (%)
................................................................................. ........................................................................... ..................................................................

Location of the pharmacy

Away from hospital 34 (56.6) 181 (72.1) 1
Near hospital 26 (43.3) 70 (27.9) 2.0 1.1–3.5 – –
Availability of vaccines
Not available 6 (10.0) 120 (47.8) 1 1
Available 54 (90.0) 131 (52.2) 8.2 3.4–19.8 7.2 2.8–18.4
Exclusive sale of drugs at the pharmacy
Yes 33 (55.5) 152 (60.6) 1
No 27 (45.5) 99 (39.4) 1.3 0.7–2.2 – –

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Alternative power supply for the refrigerator
Absent 52 (86.7) 247 (98.4) 1 1
Present 8 (13.3) 4 (1.6) 9.5 2.8–32.7 6.0 1.5–23.7
Work experience of the drug seller (years)
<8 8 (13.3) 85 (33.9) 1 1
9–11 10 (16.7) 62 (24.7) 1.7 0.6–4.6 1.8 0.6–5.2
12–15 20 (33.3) 62 (24.7) 3.4 1.4–8.3 2.3 0.8–6.0
≥16 22 (36.7) 42 (16.7) 5.6 2.3–13.5 5.5 2.0–15.2
Source of current drug knowledge
Medical representatives exclusively 36 (60.0) 187 (74.5) 1
Other than medical representatives 24 (40.0) 64 (25.5) 2.0 1.1–3.5 – –
Knowledge of whether co-trimoxazole could
be given without prescription
Yes1 30 (50.0) 83 (33.1) 1 1
No2 30 (50.0) 168 (66.9) 2.0 1.1–3.6 2.0 1.0–4.0
Knowledge of temperature range for vaccines
No 17 (28.3) 127 (50.6) 1 1
Yes 43 (71.7) 124 (49.4) 2.6 1.4–4.8 2.8 1.4–5.6
Knowledge of prescription terminology
Incorrect response 13 (21.7) 217 (86.5) 1
Correct response 47 (78.3) 34 (13.5) 23.1 11.3–47.1 – –
Practice of giving drugs without prescription
No 50 (83.3) 211 (84.1) 1 1
Yes 10 (16.7) 40 (15.9) 1.1 0.5–2.3 1.2 0.5–3.0
1
Can be given without prescription.
2
Cannot be given without prescription

developing country studies [7,9,10,14,15]. This is alarming yet
not surprising, as drug sellers play a major role in prescribing
in Pakistan, where nearly half the population lacks access to
qualified medical practitioners. Furthermore, most drug sell-
ers obtained their drug information from industry representa-
tives, also as reported from other developing country studies
[8,16].However, the promotional strategy of representatives,
extolling a drug’s benefits and minimizing side effects, is
largely dictated by financial incentives to promote sales [6,17–19].
Such marketing practices are well documented in both devel-
oping and developed countries; in the USA drug company
enticements were linked to increased prescribing of the pro-
moted drugs [20], physicians relying on representatives as
their source of information prescribe more drugs and more
often prescribe inappropriately [21]. This commercial rela-
tionship between physicians, drug sellers and representatives
plays a major role in influencing pharmaceutical practice [16].
Nearly half of pharmacies were found selling general goods
like foodstuff, cosmetics, and miscellaneous household items
along with drugs. As pharmacies can be kept open for 24
hours, it is likely that in many of these instances, drugs are
kept primarily as an adjunct to items of general use even without

311
Z. A. Butt et al.
a pharmacist present, reflecting predominantly commercial
rather than health care motivations.
Our study also examined storage practices, revealing a paucity
of temperature monitoring devices and alternative power
supplies for refrigerators, and raising doubt regarding the efficacy
of products requiring refrigeration, as also reported from
India [22]. More than half of pharmacies were keeping vac-
cines irrespective of appropriate storage, consistent with an
earlier Karachi study [7], with serious implications for vaccine
efficacy and the ultimate effectiveness of vaccination initia-
tives, at least to the extent to which population coverage is
dependent on private sector suppliers.
The assessment of baseline knowledge and practices of drug
sellers revealed that over half were unaware that co-trimoxazole
is to be sold on prescription. This drug is often used as an indi-
cator when enquiring about knowledge of antimicrobials [7].
However (although once responsible for a high sales volume in
Pakistan), co-trimoxazole’s proportional sales were low com-
pared with quinolones and cephalosporins. A possible expla-
nation could be that sale of a drug in Pakistan is largely dictated
by its profit margin. For example, quinolones have over 50
competitors in the market with prices ranging from Rs.10
(1 US$ = 60 Pak. Rs., June 2002) to Rs.31 per tablet/capsule
while cephalosporins have prices ranging from Rs.10 to Rs.20,
and it is in the economic interest of drug sellers to sell those
brand names that have a larger profit margin. The underlying
public health issue however, is that cavalier use of antimicrobials
is a major factor in the emergence of resistant organisms,
thereby undermining the efficacy of the drugs themselves.
Over half of the respondents knew the correct temperature
range for vaccines and also knew prescription terminology.
Only one-fifth admitted to giving drugs without prescription,
which may be an underestimate, given that this contravenes
correct practices.
Drug sellers with knowledge of the correct temperature
range for vaccines and knowledge that co-trimoxazole
should not be given without prescription were significantly
associated with pharmacies meeting requirements. However,
these also were more likely to give drugs without prescrip-
tion; although not statistically significant, this reveals a dis-
crepancy between knowledge and practice. Similar behaviour
is also reported from Ghana [23], while studies using the
Simulated Client Method (SCM) [24] in Vietnam and Nigeria
have also identified this discrepancy [25,26], most likely
reflecting an interplay of factors influencing behaviour:
refusal of a client’s request may lead to loss of business, while
competing drug sellers also resort to such practices to
increase profits.
Pharmacies are often the first point of contact for patients
seeking health care as they are usually more accessible and less
socially distant than other providers, including medical doc-
tors. Attempts to extend the role of pharmacists from dis-
pensers to practitioners are reported from South Africa, and
also the UK where they are used in detecting hypertension
[27,28]. A study in Ghana identified pharmacies as an accessi-
ble avenue of care in managing sexually transmitted infections
[29]. However, if drugs or vaccines are compromised by qual-
ity issues such as we have documented, households may end
312
up with products or advice that are worthless and even haz-
ardous, a false economy indeed.
Our study had limitations, but allows critical issues to be
raised relating to the public health effectiveness and safety of
drug and vaccine use in Pakistan. Due to the sensitivity of some
questions, not all answers given by drug sellers may be consist-
ent with actual practices. It is for this reason that the market
presence of counterfeit drugs could not be addressed using our
survey method, as responses to such a question would certainly
be biased. Qualitative investigations (such as SCM) are required
to explore such issues. We acknowledge that the pharmaceuti-
cal company list (used due to the absence of any more formal
listing) may not include all pharmacies in urban Rawalpindi and
could lead to a bias in sampling, although a large majority of
outlets are believed to be represented.
In many areas of public health, education holds more
promise for long-term change than does the enforcement of
legislation. In this respect, creating avenues by which sellers
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could enhance and maintain their competence and the respect
in which they are held in their communities, may be the best
long-term strategy. Such approaches have been advocated
and attempted abroad, such as in Ghana and Kenya [29,30],
and need to be tried in Pakistan, especially as (for example)
the importance of refrigeration with back-up power may sim-
ply not be understood by some commercial drug sellers.
In conclusion, involving drug sellers in diagnosis and treat-
ment, or as providers of advice for illnesses is not necessarily
an ideal situation. However, in Pakistan, they play a critical
role in reaching people in need, and have the potential to pro-
vide an accessible, reasonably private, and rapid service. In
this sense they are an underutilized community resource that
can be enhanced to improve health care.
There are implications for the GOP, with whom we are in
ongoing communication regarding the findings of this study. As
most pharmacies did not meet requirements, existing legislation
should be enforced, and licence renewal linked to an inspection
process. Incentives should be introduced to improve service
quality. In the longer term, training programmes for drug sellers
are needed to enhance knowledge and promote safer practices.
More in-depth studies are warranted to further assess the situ-
ation of Pakistan’s pharmacies and to improve the quality of
their service. Finally, no intervention will be successful without
the pharmaceutical industry’s involvement.
Acknowledgements
The authors thank the Department of Community Health
Sciences, the Aga Khan University, for funding this study and
are also grateful to the District Health Officer, Rawalpindi for
his support and Pharmacia Upjohn for providing the list of
drug sellers.
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