A scoping review of prescribing practices in Pakistan reveals persistent deviations from WHO INRUD optimal standards across all five core drug use indicators

Background Irrational drug prescribing is a significant public health challenge in low- and middle-income countries (LMICs), contributing to adverse drug reactions, antimicrobial resistance, and increased healthcare costs. Pakistan, characterised by a predominantly out-of-pocket healthcare system and limited prescription regulation, represents a high-burden setting for irrational prescribing practices. Objective This scoping review aimed to map and synthesize published evidence on drug prescribing practices across Pakistani healthcare settings using the five core World Health Organization and International Network for Rational Use of Drugs (WHO/INRUD) prescribing indicators. Methods A scoping review was conducted following the Arksey and O’Malley methodological framework and reported in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines. Four electronic databases, PubMed, Google Scholar, ScienceDirect, and PakMediNet, were searched for studies published between January 2013 and December 2024. Studies conducted in Pakistan, reporting at least one WHO/INRUD prescribing indicator, and written in English were eligible for inclusion. Titles and abstracts were independently screened by two reviewers. A descriptive synthesis approach was adopted; unweighted arithmetic means and standard deviations were calculated for each indicator. Results Of 185 records identified, 15 studies met the inclusion criteria. The unweighted mean number of drugs per prescription was 4.2 (SD ± 1.93), exceeding the WHO optimal range of 1.6–1.8. Generic prescribing stood at 24.93%, far below the WHO target of 100%. The mean antibiotic prescribing rate was 45.01%, exceeding the WHO optimal range of 20.0–26.8%. The mean injection prescribing rate was 27.34%, above the WHO optimal range of 13.4–24.1%. Essential Drug List (EDL) compliance was 72.20%, below the WHO target of 100%.The overall unweighted summary estimates deviated from WHO/INRUD optimal values across all five indicators. Conclusion Prescribing practices across Pakistani healthcare settings consistently deviate from WHO/INRUD optimal standards, with particularly critical gaps in generic prescribing and antibiotic use. Coordinated interventions are required at the regulatory, institutional, and community levels, including enforcement of generic prescribing mandates, implementation of antimicrobial stewardship programmes, and prescriber audit-and-feedback systems.