Kamuhabwa & Kisoma

Tropical Journal of Pharmaceutical Research November 2015; 14 (11): 2107-2113

ISSN: 1596-5996 (print); 1596-9827 (electronic)
© Pharmacotherapy Group, Faculty of Pharmacy, University of Benin, Benin City, 300001 Nigeria.
All rights reserved.

Available online at http://www.tjpr.org

http://dx.doi.org/10.4314/tjpr.v14i11.22
Original Research Article

Factors Influencing Prescribing Practices of Medical

Practitioners in Public and Private Health Facilities in Dar
es Salaam, Tanzania
Appolinary AR Kamuhabwa1* and Sunday Kisoma2
1 2
Unit of Pharmacology and Therapeutics, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Tanzania
Food and Drugs Authority, Dar es Salaam, Tanzania

*For correspondence: Email: [email protected], [email protected], Tel: +255 757 576985; Fax: +255
222150465

Received: 5 August 2014 Revised accepted: 8 October 2015

Abstract
Purpose: To determine the factors that influence prescribing practices of medical practitioners in public
and private health facilities in Dar es Salaam, Tanzania
Methods: One hundred and ninety two (192) medical practitioners from 11 public and 3 private health
facilities of Dar es Salaam, Tanzania were interviewed for the criteria they consider when making
prescribing decisions. Systematic sampling was used to obtain the required number of medical
practitioners working in the hospitals, while for those working in the health centers convenience
sampling was used.
Results: Medical information from textbooks (64 %) and internet (63 %) were the main sources of
prescribing information among medical practitioners. In comparison, medical practitioners in private
health facilities (97 %) were more concerned with proven effectiveness of drugs than those working in
public health facilities (74.2 %, p = 0.001). Cost of drug to patients was considered much more by
practitioners in public health facilities (48.4 %) than their counterparts in private health facilities (24.3 %,
p = 0.010). Availability of drugs in the health facility influenced prescribing decisions by a majority of
prescribers from public health facilities (53.5 %) than those working in private health facilities (18.9 %, p
= 0.000).
Conclusion: There are substantial differences between prescribers working in public and private health
facilities with regard to the factors which influence their prescribing decisions. In order to promote
rational use of medicines, these factors should be considered by health planners when formulating
policies and allocating resources in health facilities.

Keywords: Prescribing practice, Medical practitioners, Health facilities, Prescribing information, Drug
costs, Rational use, Drug effectiveness

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INTRODUCTION of one or more antibiotics were high [2].

Unnecessary prescription of injectable was also
Surveys conducted in many of the developing very high. Several factors have been identified to
countries have shown a significant degree of influence practitioners’ prescribing decisions and
inappropriate use of drugs in their health care practices [3]. Some factors such as the
facilities [1]. In most of these studies the average physicians’ age, gender, socio-economic
number of drugs per encounter and prescriptions characteristics of the practicing environment, and

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 Kamuhabwa & Kisoma

the healthcare demand are fixed and may not Doctors, Assistant Medical Officers and Clinical
offer much opportunity for modification and Officers.
improvements in prescribing behavior [4].
However, other factors including physicians’ level A descriptive cross sectional study was used to
of education and experience, frequency of visits assess the factors that influence prescribing
by pharmaceutical sales representatives, number practices of medical practitioners in Dar es
of patients examined per day, and various social Salaam. The study used a stratified sampling
factors are amenable to change and can be method in order to obtain a good representation
modified to improve physicians’ prescribing of the required health facilities as well as all the
behavior [5,6]. important cadres of medical practitioners. This
was done by assigning health facilities into
referral hospitals, municipal hospitals, private
In developing countries many factors have been
hospitals and health centers. The three largest
identified as the main contributors of the problem private hospitals were conveniently selected.
of irrational use of drugs. Such factors include These are Aga Khan Hospital, Mission Mikocheni
lack of regular and reliable facilities which Hospital and TMJ Hospital. Public health
provides up to date and unbiased information on facilities were grouped into three strata according
the currently used drugs, influence of to their levels, i.e., National Hospital, Municipal
pharmaceutical sales representatives and hospitals and Health Centers. In this case, the
inadequate training and professional Muhimbili National Hospital, Municipal Hospitals
development [2,7]. Other factors include poor and six health centers were conveniently
communication between health professional and included in the study. Systematic sampling was
patients regarding the basic information about used to obtain the required number of medical
the use of drugs. practitioners from each health facility to be
enrolled for the study. Because of the small
Most of the studies done in Tanzania on this area number of medical practitioners in the health
have examined the prescribing behavior of centers, all those who were available during the
medical practitioners working in church-owned time of the study were enrolled into the study.
and public health facilities by using WHO drug
use indicators [8,9]. Prescribing patterns Data collection
discovered from these studies must have the
underlying reasons as to why the medical Data were collected from March to June 2013.
practitioners prescribe irrationally and in the way Interviews were conducted using self-
administered questionnaires at the health
that they do. Therefore, the objective of this
facilities. The questionnaire contained 26
study was to determine the factors which
questions including medical practitioners’
influence prescribing practice in public and
demographic characteristics, prescribing
private health facilities in Dar es Salaam,
practices, sources of prescribing information and
Tanzania. Identification of these factors is their extent of use, practitioner's attitudes
important in order to institute the necessary towards use of generic medicines, and
measures for policy and regulatory interventions practitioners’ attitudes towards new discoveries
to enhance rational use of medicines. in medicine, and medicines safety. Based on the
specific category to be assessed, assessment of
EXPERIMENTAL prescribers’ attitude was done using Likert scale
in which 5 was the lowest indicator for positive
Study design and sampling attitude, while 17 indicated the most negative
attitude [10].
The study was conducted from March to June
2013 in Dar es Salaam, Tanzania. Dar es Data analysis
Salaam was selected as the study site because it
is the largest City in Tanzania with many health Data were analyzed using Statistical Package for
facilities both in urban and peri-urban areas, Social Sciences (version 15.0) computer
including the biggest referral hospital and four of software. Questions on attitudes were
the biggest private hospitals in the country. In transformed and scales assigned before
this study, 13 health facilities including 6 health frequencies were run in order to determine
centers, 4 public hospitals and 3 private hospitals proportions of medical practitioners on the
were used. The medical practitioners enrolled in attitude scales. Comparison of practitioner`s
the study included Medical Specialists, Resident responses from private health facilities with those
Medical Officers, Medical Officers, Intern from public health facilities was done by cross
tabulation against different attributes which

Trop J Pharm Res, November 2015; 14(11): 2108

 Kamuhabwa & Kisoma

frequencies had been run earlier and as per the RESULTS

specific objectives of the study. The comparisons
between the two groups were done by A total of 192 medical practitioners were enrolled
performing a Chi-square test at 95 % confidence into the study. The type of health facilities and
intervals. P < 0.05 was taken as statistically the respective number of medical practitioners
significant. who were interviewed in this study are shown in
Table 1.
Ethical considerations
The socio-demographic characteristics of the
The ethical approval to conduct the study was
sought from the Research and Publications study participants are shown in Table 2.
Committee of the Muhimbili University of Health
and Allied Sciences. The permission to conduct Factors considered by medical practitioners
the study in the health facilities was sought from before making prescribing decisions
the respective health facilities’ management.
Study participants were informed on the Medical practitioners in the private health
purposes of the study, and written consent was facilities (97 %) were more concerned with
then obtained from the study participants. proven effectiveness of a drug when making their
prescribing decisions compared to those working
in the public health facilities (74.2 %) (p = 0.001).

Table 1: Medical practitioners and type of health facility (n = 192)

S/N Health facility Type of facility Number of

practitioners
1 Muhimbili National Hospital Referral hospital 50
2 Mwananyamala Hospital Municipal hospital 25
3 Temeke Hospital Municipal hospital 25
4 Amana Hospital Municipal hospital 25
5 Aga Khan Hospital Private hospital 15
6 Mission Mikocheni Hospital Private hospital 15
7 TMJ Hospital Private hospital 10
8 Magomeni Health Center Health center 5
9 Sinza Health Center Health center 5
10 Mnazimmoja Health Center Health center 4
11 Buguruni Health Center Health center 3
12 Kigamboni Health Center Health center 5
13 Vijibweni Health Center Health center 5

Table 2: Socio-demographic characteristics of medical On the other hand, the cost of the drug to the
practitioners interviewed in the study (n = 192) patient was found to be more influential to
practitioners working in the public health facilities
Variable Number %
(48.4 %) compared to their counterparts working
Sex
Male 124 64.6 in the private health facilities (24.3 %) (p =
Female 68 35.4 0.010). Availability of drugs in the health facilities
was also a factor considered mostly by
Age Group (Years) prescribers from public health facilities (53.5 %)
21-30 70 38.5 than those working in the private health facilities
31-40 76 41.5
(18.9 %, p = 0.000) (Table 3).
41-50 27 15.1
> 50 9 4.9
Medical practitioners’ sources of prescribing
Cadres information and their preferences
Medical specialist 29 15.4
Medical Officer 67 35.6 Results show that 91 % of medical practitioners
Intern Doctor 31 16.5 routinely search for information to guide their
Assistant Medical Officer 20 10.6
Clinical Officer 24 12.8 prescribing decisions. Information from medical
Resident 17 9.0 textbooks are widely used (64 %) followed by
internet (63 %) and medical journals (39.7 %).
Health Facility Advice from colleagues was reported by 33 % of
Public 155 80.7 the respondents while information from
Private 37 19.3 pharmaceutical sales representatives ranked the
Trop J Pharm Res, November 2015; 14(11): 2109
 Kamuhabwa & Kisoma

Table 3: Comparison of factors considered when making prescribing decisions between practitioners from public
and private health facilities (n = 192)

Factor Private facilities (%) Public facilities (%) P-value

Proven clinical effectiveness 97 74.2 0.001
Pharmaceutical delivery mode 13.5 17.4 0.485
Recommended daily dose 18.9 21.3 0.826
Cost to the patient 24.3 48.4 0.010
Patient preference 5.4 7.1 1.00
Drug availability 18.9 53.5 0.000
Others 0 2 1.000

Table 4: Comparison of reasons for information search between practitioners from private and public health
facilities (n = 192)

Factor Private facilities (%) Public facilities (%) P-value

Dose 68.6 62.0 0.559
Adverse drug reactions 54.3 67.6 0.167
Interactions 57.1 64.1 0.444
Precautions in pregnancy 54.3 58.5 0.705
Precautions in breastfeeding 45.7 48.6 0.851
Drug toxicities 20.0 41.5 0.020
Chronic diseases 17.1 25.4 0.379

last (16.4 %) among the reliable sources of About a third of the prescribers from private and
information for prescribing. public health facilities indicated that the main
reason for using the above mentioned sources of
Adverse drug reactions (ADRs) (65 %), Dose prescribing information is to get the accurate
(63.3 %) and drug-drug interactions (62.7 %) doses of the drugs. Practitioners from public
were the most common reasons that make health facilities were more concerned about
medical practitioners search for information from occurrence of ADRs (67.6 %), drug-drug
the above mentioned sources. Other reasons interactions (64.1 %), precautions in pregnancy
were precaution during pregnancy (57.6 %), (58.5 %), breastfeeding (48.6 %), toxicities in
breastfeeding (48 %), known toxicity of the drug vital organs (41.5 %) and existence of chronic
to vital organs (37.3 %) and existence of chronic diseases (25.4 %). With regard to checking for
diseases in patients (23.7 %). With regard to new information on drug toxicities on vital organs, 41
medicinal products, scientific medical journals % of practitioners from public health facilities
were reported to be widely used (45 %) by sought information on this aspect compared to
medical practitioners, followed by internet (44 %) 20 % of their counterparts in the private health
and medical presentations in different forums (38 facilities (Table 4).
%). Information by pharmaceutical sales
representatives were the least (22.5 %) preferred Medical practitioners’ attitude towards use of
source of prescribing information when generic drugs
practitioners encountered a new medicinal
product. Overall, about 90 % of all medical practitioners
were in favor of prescribing generic drugs. More
In order to obtain information about ADRs, practitioners from public health facilities (45.8 %)
prescribers in the private health facilities prescribed generic drugs compared to those
preferred using publications from medical working in the private health facilities (37.8 %).
journals (42.9 %) compared to those from public With regard to quality, safety and effectiveness of
facilities (36.6 %, p = 0.561). The extent for the generic medicines, 50 % of all medical
use of medical textbooks was similar among the practitioners indicated that the drugs have
practitioners working in the public health facilities satisfactory quality, safety and efficacy.
(65.7 %) and those working in the private health
facilities (64.1 %). Likewise, there were no Analysis of data by combination of questions
statistically significant differences observed in the regarding prescribers` attitudes on generic drugs
utilization of the rest of the sources of prescribing with respect to safety and effectiveness indicated
information between the two groups of medical that more than 80 % of medical practitioners had
practitioners (p > 0.05).

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 Kamuhabwa & Kisoma

positive attitudes towards generic drugs (Table most common diseases is often empirical i.e.,
5). treatments are started before obtaining
laboratory investigation results [11]. In such a
Table 5: Medical practitioner’s attitudes on generic situation, most of medical practitioners would
drugs with regard to quality, safety and efficacy (n = prefer to prescribe a drug whose clinical
192) effectiveness is well proven and documented for
the suspected indication. This is also in line with
Attitude Medical practitioners Cumulative
the findings of a study that was designed to
scale grouped according to (%)
attitude scale (%)
describe and compare opinions of physicians,
5 10.6 10.6
clinical pharmacists, and drug formulary
6 5.8 16.4 committee members with respect to key factors
7 8.5 24.9 that influence medication prescribing in
8 12.2 37.0 community hospitals [3]. In the later study,
9 15.3 52.4 safety, effectiveness and restrictions on
10 19.0 71.4 prescribing were the most influential factors for
11 13.2 84.7 prescribing.
12 5.8 90.5
13 5.8 96.3
The observation that proven clinical effectiveness
14 1.6 97.9
15 1.1 98.9
of the drug was mostly considered by
16 0.5 99.5 practitioners from private health facilities is due
17 0.5 100 to the fact that in Tanzania, public health facilities
are often faced with shortage of medicines [12].
As a result, there is not much to choose from
Comparison between medical practitioners in the
treatment options. Majority of patients visiting
public and those in private health facilities shows
these facilities are of lower socio-economic
that majority of practitioners in the public health
status and therefore may not afford the
facilities (89 %) and those in the private health
expensive medications which are most effective
facilities (78.6 %) believe that generic drugs are
for particular disease indications. Subsequently,
of excellent and good quality. Medical
medical practitioners are confined into
practitioners’ opinions on the effectiveness of
prescribing the least expensive available drug
generic drugs show that 89.2 % of practitioners
that would be affordable to patients [13].
in the private health facilities believe that generic
drugs are of excellent or satisfactory
Majority of medical practitioners in this study rely
effectiveness compared to 78.7 % of
on multiple sources of drug information for
practitioners from public health facilities (p =
prescribing. Similar pattern for use of drug
0.171).
information resources has been reported among
medical practitioners in Ireland [14]. In the latter
Thirty nine percent (39 %) of medical
study, drugs and therapeutics bulletin and
practitioners did not believe that high price of
medical journal articles were rated among the
new drugs imply better effectiveness compared
most preferred sources of prescribing information
to those who do believe so (38 %). The similarity
for both old and new medicines. This is somehow
in this aspect is regardless of the fact that
different with the findings of the present study
majority of medical practitioners were in favor of
where medical textbooks were the most used
the effectiveness of new drugs (52 %) compared
sources of prescribing information. This is
to those (19 %) who believed that there is no
probably due to the fact that medical textbooks
significant difference between new drugs and old
are the most accessible sources of prescribing
drugs already available on the market. Combined
information to medical practitioners in Tanzania
data on attitudes towards new drug products
[15].
indicated a balance between the proportion of
medical practitioners with positive attitude and
In this study, internet was reported to be widely
those with negative attitude towards generic
used by medical practitioners working in the
drugs.
public and private health facilities. It is
understandable that there has been a massive
DISCUSSION move towards an effective use of information and
communication technology in all sectors
Proven clinical effectiveness was seen as the including health care. This has been
most important criterion considered by medical advantageous in health since medical
practitioners from both private and public health practitioners can obtain much information on
facilities when prescribing. This is likely due to medicine and medical supplies quite easily
the fact that in Tanzania, like in many other through the internet. Therefore, it is necessary to
developing countries, treatment especially of
Trop J Pharm Res, November 2015; 14(11): 2111
 Kamuhabwa & Kisoma

consider increasing access to computers and prescribing decisions. In terms of the factors
internet connectivity in the health facilities. considered by prescribers to prescribe a
particular drug, there were differences between
In this study medical journals were another those working in the public health facilities and
important source of prescribing information. This private facilities. However, for majority of
could be attributed to the fact that most of the prescribers, cost of drugs to the patients was an
journals contain well researched scientific important factor influencing prescribing. In order
articles. Therefore information from these to increase access to essential medicines, the
sources is most likely to be widely relied upon by government should expand coverage of the
medical practitioners for their prescribing. The health insurance scheme beyond the
main challenge regarding the use of this source
government employees.
of information is low capacity of subscription to
these journals among medical practitioners in
Tanzania. Limitation of the study

The use of generic drugs is encouraged because The study was conducted in Dar es Salaam,
they are cheaper than branded substitutes, and which is a commercial capital with relatively well
in most cases they have equal potency to that of staffed health facilities. Therefore, the situation
the branded ones [16]. In a study conducted in may be different in other health facilities,
twelve developing countries in 1987, only 17 % especially in the rural areas of the country. It is
of drugs prescribed in the rural health facilities therefore recommended that a similar study be
were prescribed in their generic names [1]. conducted in other regions in the country to
However, a study conducted in 1993 in Tanzania determine the factors that influence prescribing
found that 84 % of drugs were prescribed in their practices of medical practitioners in these areas.
generic forms [17]. Thus the observation that
majority (90 %) of medical practitioners in this ACKNOWLEDGEMENT
study prescribe generic drugs on regular basis is
a reflection of the situation in Tanzania where The authors wish to express their sincere
more than 80 % of drugs circulating in the market appreciation to the medical officers in charge of
are generics [18]. This is also in support of the the three municipal hospitals and Muhimbili
government initiative advocating for the use of National Hospital for granting permission to
generic drugs in order to minimize unnecessary conduct the study in the health facilities. Thanks
costs of healthcare budgets. also to the management of the private hospitals
for granting permission to conduct the study in
Generally practitioners in the private health
their respective hospitals as well as to all the
facilities have a greater trust in quality, safety
prescribers who agreed to spend their time to
and effectiveness of generic drugs. Between the
participate in the study.
two sets of medical practitioners, those from
private health facilities were more in favor of the
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