Non-prescription antibiotic dispensing in community pharmacies in LMICs: a systematic review of prevalence, drivers, and policy implications

Abstract

Background

Community pharmacists dispensing antibiotics without a prescription (DAwP) remain a contributing factor to antimicrobial resistance (AMR) in low- and middle-income countries (LMICs). Multiple structural, behavioral, and systemic factors influence this practice, yet the diversity and interaction of these drivers remain insufficiently explored.

Objective

This systematic literature review aims to identify and synthesize the internal and external factors contributing to DAwP among community pharmacists in LMICs, integrating evidence from both qualitative and mixed-method studies to offer updated, context-specific insights.

Methods

A comprehensive literature search was conducted up to August 2025 across PubMed, Scopus, EBSCO, and Web of Science (WoS) using Boolean search techniques, with no restrictions on publication date or language. Studies were screened according to predefined eligibility criteria, focusing on primary research conducted in LMICs. The review included quantitative, qualitative, and mixed-methods studies. The review protocol was registered in PROSPERO (CRD420251108428).

Results

A total of 24 studies were included. Quantitative synthesis revealed an alarmingly high prevalence of DAwP, averaging 66.6% (range: 25.9–100%) across included surveys, highlighting a significant gap between professional knowledge and practice. Factors influencing DAwP were categorized into seven major themes: (1) economic and socio-demographic factors, (2) pharmacy and pharmacist characteristics, (3) knowledge and attitudes, (4) customer demand and behavior, (5) regulatory and legal environment, (6) healthcare system limitations, and (7) interventions and solutions. While awareness of AMR exists, weak enforcement, patient pressure, and systemic healthcare gaps perpetuate non-compliant dispensing practices.

Conclusion

DAwP in LMICs results from a complex interaction of individual, institutional, and policy-level factors. Addressing this requires comprehensive strategies—regulation, education, systemic transformation, and community involvement—to minimize incorrect antibiotic usage and combat AMR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14194-x.

Introduction

Antimicrobial resistance (AMR) is a global health concern, particularly in low- and middle-income countries (LMICs) where healthcare system issues and either misuse or overuse of antibiotics occurred [1, 2]. Dispensing antibiotics without prescriptions (DAwP) and other public health problems are indicated to influence AMR [3, 4].

Community pharmacists and their practices in LMICs are crucial to primary healthcare, particularly regarding DAwP. Community pharmacists often serve as accessible sources of medication information and counseling for self-care in LMICs [5]. This role is especially prominent in LMICs, where self-medication often involves antibiotics. Other factors that correlated with the issue are insufficient regulatory enforcement, limited physician accessibility, patient demand, financial limitations, and pharmacists’ professional judgment [6, 7]. The WHO estimates that 20–50% of antibiotics in developing nations are overused, with DaWP selling up to two-thirds of medicines [8].

The misuse of antibiotics, including practices such as self-medication, underdosing, and poor adherence, is well known. The characteristics that affect how community pharmacists in LMICs administer antibiotics are poorly understood or summarized across settings. These factors must be identified for effective interventions and regulation [9].

AMR constitutes a significant global public health crisis, diminishing the efficacy of antibiotics and complicating the management of infectious diseases worldwide. Inappropriate antibiotic use is widely identified as a principal and modifiable driver of AMR, with the DAwP representing a particularly widespread practice. DAwP are most common in LMICs, where weak regulatory enforcement, ineffective implementation of medicines policies, and limited access to affordable healthcare services lead patients to obtain antibiotics directly from drug outlets. As a result, DAwP often leads to unsupervised antibiotic use, such as incomplete treatment courses and inadequate dosing instructions, which promote the emergence and community-level transmission of antibiotic-resistant bacteria [10, 11].

This systematic review covers a major research gap by expanding beyond qualitative data-only reviews [12]. While previous reviews have focused primarily on qualitative explanations of dispensing behavior, there remains a gap in synthesizing quantitative and mixed-methods evidence that can inform the relative importance and prioritization of drivers for policy action. This study also provides an updated synthesis that accounts for new practices and contextual changes, providing updated evidence relevant to LMICs antimicrobial stewardship and regulatory initiatives. In addition to synthesizing drivers, we sought to derive policy implications; therefore, we considered intervention/evaluation evidence only where it explicitly reported underlying barriers/drivers relevant to DAwP.

Methods

Search strategy

This systematic review adopted the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines [13]. We searched four primary health science databases: PubMed, Scopus, EBSCO and Web of Science (WoS). We produced various term combinations using Boolean operators (AND/OR) in our literature search:

((((Antibiotic) AND (Dispensing)) AND (without Prescription)) AND (Community Pharmacist)) AND (Low Income Countries)) AND (Middle Income Countries).

No restrictions on date or language were established. The literature search was conducted up to 29 August 2025. In the Scopus database, document types classified as articles and editorials are filtered and excluded during the search process. Distinct searches were conducted in each database, after which the results were merged and de-duplicated in Rayyan AI to filtering all entries for relevance to the review. The study protocol was registered on PROSPERO under registration number CRD420251108428.

Selection criteria

This study evaluated the relevance of each included article based on established eligibility criteria aligned with the primary research question: Among community pharmacists in low- and middle-income countries (P), what is the prevalence of dispensing antibiotics without a prescription, and what factors (O) are associated with this practice (I)?

The study applied the following inclusion criteria: (i) primary research studies reporting empirical findings; (ii) full-text articles retrieved from PubMed, Scopus, EBSCO, and Web of Science (WoS) and indexed in at least one of these databases; and (iii) studies conducted in LMICs. Eligible studies included quantitative, qualitative, and mixed-methods designs that reported the prevalence of non-prescription antibiotic dispensing and/or examined factors associated with this practice. Intervention or implementation evaluation studies were included only if they reported explicit and extractable information on drivers or barriers of DAwP (e.g., customer demand, market pressure, regulatory or supervision gaps), rather than reporting intervention effectiveness alone. Studies were excluded if they were review articles, commentaries, editorials, conference abstracts without full text, or did not report empirical data relevant to DAwP in LMIC settings.

Screening and eligibility assessment

Established criteria were applied to identify relevant studies. After all qualifying articles were identified, duplicates were removed. Study-related abstracts and keywords were then selected. Article eligibility was assessed according to predefined inclusion criteria. Subsequently, the full texts of the articles were reviewed, rather than relying solely on abstracts and keywords. Content analysis was conducted to clarify the review process and address research questions concerning DAwP in LMICs.

Data extraction

A total of 601 research articles were initially included from four databases. After removing 48 duplicate articles, 553 articles were screened for relevance based on their titles and abstracts. Subsequently, 529 articles were excluded from the study, leaving us with 25 full-text articles for further assessment. Out of these 25 studies, one was excluded for not fulfilling the inclusion criteria. This resulted in the final inclusion of 24 studies in the systematic review. The PRISMA flowchart in Fig. 1 clearly illustrates this process. The study designs and geographic distribution of the included studies are shown in Fig. 2.

Fig. 1.

PRISMA diagram outlining the screening and selection process in literature search

Fig. 2.

Study design and location studies included in literature search

Data synthesis and analysis

A thematic synthesis approach was employed to integrate findings across diverse study designs. Codes and themes were generated inductively from the extracted data and iteratively refined. Seven overarching themes were identified to organize the factors influencing DAwP. Where available, triangulation of data across different study types (e.g., simulated patient vs. self-reported surveys) was conducted to validate findings. Data on the prevalence of non-prescription antibiotic dispensing were extracted and summarized descriptively using reported proportions.

Result

A total of 601 studies were identified, of which 24 were incorporated into the comprehensive content analysis (Table 1). This evaluation aimed to enhance the comprehensiveness of data interpretation, offering key insights into factors affecting non-prescribing antibiotic consumption in LMICs.

Table 1.

Studies characteristics

Author (Year)	Study Design and Location	Data Collection Methods	Number of Pharmacies Involved (Sample Size)	Study Purpose
Abdelrahman Hussain et al., 2022	A cross-sectional- Sudan	Online semi-structured questionnaire	1217 pharmacist	Assess the knowledge, attitudes, and practices of community pharmacists and the factors influencing DAwP
Farah et al., 2015	A cross-sectional- Lebanon	Pharmacies were categorized into two groups based on the socio-economic status of the population located in the nearby location. Pharmacists completed a self-administered questionnaire	100 pharmacists	Evaluate the dispensing policy for non-medical prescription antibiotics in community pharmacies, considering the impact of the area’s socioeconomic conditions
Salah et al., 2025	A cross-sectional-Egypt	Online questionnaire to different 5 Egyptian governorates	117 community pharmacists	This study assesses community pharmacists’ knowledge and practices regarding antibiotic dispensing in pharmacies across several Egyptian provinces
Ferdiana et al., 2024	A pre-post quasi-experimental study-Indonesia	A seven-month program consisting of: (1) online training sessions for pharmacists; (2) awareness campaigns focused on customers; (3) peer visits; and (4) branding and certification for pharmacies	80 pharmacies	Assess the effects of a comprehensive intervention aimed at addressing this issue in urban community pharmacies in Indonesia
Gladys et al., 2025	A cross-sectional- Nigeria	A validated, self-administered questionnaire available online	420 community pharmacists	This study examines the prevalence and characteristics of community chemists dispensing antibiotics without a prescription in Nigeria and the factors associated with this practice
Hung et al., 2023	A cross-sectional- Vietnam	self-administered questionnaire	180 pharmacies	Assess the attitudes, behaviors, and pertinent factors influencing drug dispensers in the dispensing of antibiotics without a prescription in community pharmacies
de Souza et al., 2022	A cross-sectional- Brazil	Simulated patient (SP) technique	54 pharmacies	Assess the conduct of pharmacists in the distribution of antimicrobials within community pharmacies in northeastern Brazil
Ngyedu et al., 2023	A cross-sectional- Ghana	SP technique	265 community pharmacists	This study examines the prevalence and practice of dispensing antibiotics without prescriptions in community pharmacies and drug outlets in Ghana, aiming to quantify and characterize the issue to inform future interventions
Belachew et al., 2023	Qualitative study- Ethiopia	SP technique	18 community pharmacists and 5 decision makers	Analyze the perspectives of various stakeholders regarding the factors influencing and potential solutions for the dispensing of non-prescribed antibiotics in community drug retail outlets (CDROs) in Ethiopia
Ndaki et al., 2023	Qualitative study- Tanzania	In-depth interviews conducted face-to-face with drug dispensers	12 community pharmacies and 16 accredited drug dispensing outlets	Investigate the practices and motivations for dispensing antibiotics without a prescription in community drug outlets in Tanzania
Kotwani et al., 2021	Qualitative study-India	In-person comprehensive interviews	22 pharmacists and 14 informal dispensers from 36 retail pharmacies	Examine the OTC sale of antibiotics at retail pharmacies and clarify its underlying drivers
Wulandari et al., 2021	Mixed-method study- Indonesia	Standardised patients (SPs) followed by in depth interviews	There was a total of 495 visits to 166 drug outlets, which include community pharmacies and drug stores	Evaluate the prevalence and factors influencing the inappropriate dispensing of antibiotics at licensed private drug retail outlets in Indonesia
Zawahir et al., 2021	A cross-sectional-Sri Lanka	self-administered questionnaire	369 pharmacies	This study investigates the attitudes of pharmacy staff towards the supply of antibiotics for common infections in Sri Lanka
Acharya et al., 2021	Mixed-methods assessment- Nepal	Both qualitative structured interviews and a cross-sectional survey were utilized in the study	111 pharmacy owners and managers	The aim is to assess the economic and social factors that influence the dispensing of antibiotics without a prescription by community pharmacies in Nepal
Ferdiana et al., 2021	Qualitative study- Indonesia	In-depth interviews	Pharmacy and drug store staff (n = 31) and their clients (n = 28)	An enhanced understanding of dispensing practices is crucial for shaping national, regional, and global strategies to combat AMR
Ahmad et al., 2022	A cross-sectional- Pakistan	SP technique	310 community pharmacies	This study aims to evaluate the prevalence of antibiotic dispensing without a prescription in community pharmacies within the Hazara Division
Torres et al., 2020	Qualitative study-Mozambique	In-depth interviews	17 pharmacists	This study explores the practices and factors that contribute to the dispensing of non-prescribed antibiotics in Maputo, Mozambique
Poyongo & Sangeda, 2020	A cross-sectional study Tanzania	Online semi-structured questionnaire	1100 licensed pharmacists	The study purpose is to assess licensed pharmacists’ knowledge of the legal requirements for antibiotic dispensing and AMR, and to describe their dispensing practices, particularly the prevalence and drivers of dispensing antibiotics without a prescription (including commonly dispensed antibiotic classes)
Ntizala et al., 2020	A cross-sectional- Democratic Republic of Congo	A cross-sectional questionnaire-based	1504 patients and 40 pharmacies	To evaluate the antibiotic dispensing patterns in community pharmacies of the Eastern DRCongo
Abubakar & Tangiisuran, 2020	Prospective cross-sectional study-Nigeria	self-administered questionnaire	98 community pharmacists	To evaluate knowledge, perception and practices of community pharmacists towards dispensing antibiotics without prescription
Kumar et al., 2022	Cross sectional questionnaire based-India	self-administered questionnaire	75 community pharmacists	Assess the community pharmacists’ knowledge of antibiotics, their attitude toward antibiotic usage and antibiotic resistance, and their nonprescription dispensing practices of antibiotics
Alkadhimi et al., 2020	A qualitative design-Iraq	Face-to-face semi-structure interview	20 community pharmacists	To understand the dispensing practice of antibiotics in community pharmacy in Iraq, in addition to explore the community pharmacists’ perception about dispensing antibiotics without prescription
Barker et al., 2017	Mixed-methods study-India	Semistructured interviews and a pilot cross-sectional survey	24 community pharmacy employees	Seeks to better understand the factors that drive inappropriate antibiotic dispensing among pharmacy employees in India’s village communities
Gebretekle & Serbessa, 2016	Qualitative study- Ethiopia	Semi-structure interview	Five community pharmacies	To explore reasons for over the counter sale of antibiotics in the community pharmacies of Addis Ababa, Ethiopia

All studies included were conducted in LMICs using a combination of cross-sectional, qualitative, mixed-method, and quasi-experimental designs. This review encompassed 24 studies across 17 LMICs, with the highest number conducted in Asia (n = 12) [14–25], followed by Africa (n = 11) [11, 26–35], and one from South America (Brazil) [36]. Eleven studies employed self-administered or online questionnaires, while others utilized the SP method (n = 4), in-depth interviews (n = 6), or a combination of methods (n = 3). A total of approximately 6,747 respondents or pharmacy visits were reported across the studies, ranging from 5 community pharmacies in Ethiopia [28] to 1,544 participants (patients and pharmacies) in the Democratic Republic of Congo [32] and 1,217 community pharmacists in Sudan [30]. Numerous studies have focused on evaluating knowledge, attitudes, and practices (KAP) regarding DAwP [27], while other research has explored contextual factors [16, 17, 22, 24, 27, 28, 32] and the impact of multifaceted interventions [20]. All studies clearly defined their data collection, participants, and data sources, and consistently examined factors contributing to DAwP in community drug retail settings, despite methodological diversity.

Each of the research designs applied in the reviewed studies—cross-sectional surveys (n = 13), qualitative studies (n = 7), mixed-method approaches (n = 3), and quasi-experimental designs (n = 1)—offered unique benefits for comprehending the complex drivers of DAwP. Pharmaceutical knowledge, attitudes, and practices were measured at one time using self-administered questionnaires in cross-sectional surveys, similar to Salah, et al. (2025) in Egypt [37] and Hung, et al. (2023) in Vietnam [21]. This technique allowed broad generalizations but limited causal inferences. Qualitative studies in Mozambique [38], India [22], and Ethiopia [27] employed thematic analysis and in-depth interviews to gain a deeper understanding of pharmacists’ interactions with systemic, regulatory, and sociocultural factors. Additionally, SP studies in Pakistan [15] and Brazil [36] provided observational data on real-world practices, allowing observation of differences between reported and actual behaviors. However, mixed-methods and quasi-experimental research, such as that by Ferdiana, et al. (2024) in Indonesia [20], incorporated interventions, interviews, and SP visits to support intervention outcomes and provide evaluative depth. This mixed-methods evaluation was retained because it reported persistent barriers and drivers, such as customer demand, market pressure, and limited pharmacist supervision, which were relevant to our driver-focused synthesis.

To delineate the magnitude of inappropriate dispensing, a quantitative synthesis of the included studies (n = 16) reveals that the prevalence of DAwP varies significantly across regions but remains alarmingly high, ranging from 25.9% to 100%. The average prevalence reported across these studies indicates that approximately two-thirds (66.6%) of community pharmacists in the reviewed LMICs engage in this practice. Notably, dispensing rates exceeding 80% were documented in India (100%) [17], Nigeria (98.1%) [29], Pakistan (95.5%) [15], and Ghana (88.3%) [31]. In contrast, lower rates, below 40%, were observed in Lebanon (32%) [18], Sri Lanka (30%) [25], and Brazil (25.9%) [36]. Quantitative assessments of pharmacists’ knowledge in survey-based studies [23, 30, 33] revealed a pronounced knowledge-practice gap: although 61.7% to 77.7% of pharmacists reported awareness of antibiotic regulations, actual compliance was substantially lower. These findings suggest that, despite regulatory awareness, pharmacists frequently dispense antibiotics without prescriptions, likely due to external pressures such as patient demand or economic incentives.

The issue of DAwP remains a critical public health concern in LMICs, as complex, interrelated factors sustain this practice:

Economic and Socio-Demographic factors

Community economics consistently affect DAwP. Limited financial resources lead pharmacies in economically deprived communities to dispense antibiotics without prescriptions [18, 24, 30]. Antibiotic dispensing without prescriptions is more common in Lebanon, particularly for vulnerable groups like children [18]. In Nigeria and Indonesia, pharmacists cited patients’ inability to finance medical consultations as a reason for bypassing prescriptions [24, 29]. In India, Barker, et al. (2017) [17] highlighted that pharmacy employees often dispensed antibiotics without prescriptions to retain customers and ensure business survival, fearing that refusal would drive clients to competitors. Similarly, in Ethiopia, Gebretekle and Serbessa (2016) [17] reported that retail profit margins and the need to clear expiring stock were primary motivations for pharmacists to bypass prescription requirements.

Pharmacy and pharmacist characteristics

Pharmacy ownership status and qualified staff substantially impact DAwP practices. 87.4% of Nigerian pharmacies were independently operated and were more likely to prescribe antibiotics without a prescription, based on clinical experience [29]. The absence of a qualified pharmacist during service hours in Indonesia led to an increase in antibiotic sales without prescriptions [20]. According to Salah, et al. (2025), 94% of Egyptian pharmacists admitted to prescribing antibiotics without prescription, despite moderate to high awareness of AMR and regulatory limits [34]. Barker, et al. (2017) observed that in many rural Indian pharmacies, dispensing was often carried out by employees with varying levels of formal training, who prioritized customer satisfaction over clinical guidelines [17]. In Tanzania, Poyongo and Sangeda (2020) noted that while licensed pharmacists generally understood the risks, the day-to-day dispensing in drug outlets was often managed by staff with limited authority to enforce prescription-only regulations [26].

Knowledge and attitudes

Multiple studies show community pharmacists’ antimicrobial resistance knowledge–practice gap. Despite being aware of the hazards, most Egyptian pharmacists practice DAwP [34]. In Sudan, good knowledge and positive attitudes did not prevent frequent DAwP, often driven by patients’ financial constraints [30]. Although attitudes and knowledge did not affect dispensing behavior in Vietnam, perceived control and social norms did [21]. In Nigeria, Abubakar and Tangiisuran (2020) [26] found that although community pharmacists possessed adequate knowledge of AMR, this did not translate into strict adherence to dispensing laws due to perceived necessity. Conversely, in India, Kumar, et al. (2022) [23] identified significant gaps in pharmacists’ knowledge regarding specific antibiotic resistance patterns, which contributed to inappropriate dispensing. Similarly, Poyongo and Sangeda (2020) [33] in Tanzania reported that while pharmacists were aware of legal requirements, their attitude was heavily influenced by the practical need to serve patients who could not afford physician visits. While knowledge and positive attitudes towards antibiotic use and resistance are crucial, they alone do not prevent the dispensing of antibiotics without a prescription.

Customer demand and behavior

Patient expectations and demand are key drivers of non-prescription antibiotic sales. Pharmacists in Egypt, Indonesia, and Nigeria regularly face patient pressure to prescribe antibiotics for minor ailments [20, 29, 34]. Gebretekle and Serbessa (2016) [28] reported that in Ethiopia, pharmacists frequently encounter aggressive demands from patients who prefer direct purchase to save time and avoid consultation fees. Similar findings have been documented by Alkadhimi, et al. (2020) [16] in Iraq and Ntizala, et al. (2020) [32] in the Democratic Republic of Congo, where pharmacists reported feeling compelled to dispense antibiotics to meet patients’ expectations for rapid recovery and to prevent conflicts. Some pharmacists felt obligated to cooperate to maintain customer loyalty. Patients find pharmacies more convenient and accessible than professional health facilities, particularly for common diseases including upper respiratory tract infections and diarrhea [20, 29].

Regulatory and legal environment

Another prominent theme in the literature is the lack of effective regulatory enforcement. While regulations exist in many LMICs, implementation is often inconsistent and weak. In Egypt, pharmacists continued to engage in DAwP despite awareness of its illegality, with some expressing uncertainty about the actual legal requirements, highlighting a communication gap in enforcement policies [34]. In Nigeria, 34% of pharmacists reported no punishments for prescription law violations and few regulatory inspections [29]. In Indonesia, inadequate control by the health authority allowed this practice to continue unchecked [24]. Alkadhimi, et al. (2020) [16] characterized the regulatory environment in Iraq as inadequate for deterring non-prescription sales, reporting that pharmacists perceived an absence of meaningful consequences for violations. In Tanzania, Poyongo and Sangeda (2020) [33] observed that, although legal frameworks exist, inconsistent monitoring and enforcement have enabled DAwP to remain a routine practice.

Healthcare system factors

LMICs often lack accessible and affordable healthcare, forcing patients to rely on community pharmacies as their initial point of contact. Regulatory frameworks prohibiting practices of DAwP, but systemic healthcare factors such as limited access to formal healthcare and weak enforcement, create an environment in which pharmacies become the primary source of antibiotics for many patients [10, 14, 39].

Pharmacists in Mozambique and Indonesia acknowledge that under-resourced healthcare systems and lengthy wait times in public clinics prompt patients to seek quick answers in pharmacies [24, 35]. In Sri Lanka, rural healthcare absences led to self-medication and pharmacy-based treatment [25]. Barker, et al. (2017) [17] observed that in rural India, limited access to public healthcare facilities and the high cost of private medical practitioners positioned pharmacies as the primary source of care for various ailments. Similarly, Gebretekle and Serbessa (2016) reported that in Ethiopia, prolonged waiting times at clinics deterred patients from obtaining formal prescriptions, which in turn increased the responsibility of community pharmacists to diagnose and manage infections [28].

Interventions and recommendations

Multiple strategies have been shown to effectively address inappropriate antibiotic dispensing in the literature. In Indonesia, a seven-month program that incorporated pharmacist Education, peer monitoring, public awareness, and certification reduced DAwP by 20.9% [20]. These intervention findings are presented to inform viable policy options; the insights regarding drivers and barriers embedded within the evaluation (rather than the effectiveness estimate itself) were prioritized in our thematic synthesis. One solution proposed in Nigeria is mandatory health insurance, AMR stewardship programs, and greater pharmacist accountability [29]. Researchers in Egypt and Indonesia emphasize the importance of public Education programs in modifying patient expectations regarding antibiotic use [20, 34]. Table 2 presents a thematic framework summarizing the main themes, sub-themes, and representative studies. Abubakar and Tangiisuran (2020) [26] argued that educational interventions should extend beyond clinical knowledge to encompass behavioral and ethical decision-making. Additionally, Barker, et al. (2017) [17] and Kumar, et al. (2022) [23] highlighted the importance of strengthening primary care infrastructure to decrease dependence on pharmacies for diagnosis, as well as enforcing existing dispensing laws more rigorously.

Table 2.

Thematic framework

Main Theme	Sub-Themes	Representative Studies
1. Economic and Socio-Demographic Factors	Profit Maximization: Selling antibiotics to increase daily revenue and profit margins Business Survival: Fear of losing customers to competitors if the request is refused Inventory Management: Pressure to sell stock nearing expiration dates	Barker, et al. (2017); Gebretekle & Serbessa (2016); Hussain, et al. (2022); Acharya, et al. (2021); Hung, et al. (2023); Ndaki, et al. (2023); Gladys, et al. (2025)
2. Pharmacy and Pharmacist Characteristics	Staff Qualifications: Dispensing by non-pharmacist staff or untrained employees Owner Influence: Employees forced to dispense against rules by pharmacy owners Retail Setting: Commercial orientation of retail chains vs. independent pharmacies	Barker, et al. (2017); Ngyedu, et al. (2023); Ahmad, et al. (2022); de Souza, et al. (2022); Acharya, et al. (2021)
3. Knowledge and Attitudes	Knowledge Gaps: Misconceptions about antibiotic efficacy for viral infections or AMR mechanisms Attitude-Practice Gap: Pharmacists know the regulations but violate them due to external pressures Moral Obligation: Feeling compelled to help sick patients who cannot afford doctors (sympathy)	Kumar, et al. (2022); Abubakar & Tangiisuran (2020); Hung, et al. (2023); Poyongo & Sangeda (2020); Ferdiana, et al. (2021); Farah, et al. (2015)
4. Customer Demand and Behavior	Patient Pressure: Aggressive demand, threats to go elsewhere, or request for “quick relief” Specific Requests: Patients demanding specific brands or repeating previous prescriptions Conflict Avoidance: Pharmacists dispensing to maintain good relationships and avoid disputes	Alkadhimi, et al. (2020); Zawahir, et al. (2021); Wulandari, et al. (2021); Salah, et al. (2025); Torres, et al. (2020); Ngyedu, et al. (2023); Farah, et al. (2015)
5. Regulatory and Legal Environment	Weak Enforcement: Lack of regular inspections, monitoring, and government oversight Insufficient Penalties: Sanctions are either non-existent, too light, or not implemented Legal Ambiguity: Confusion or lack of awareness regarding specific dispensing laws	Poyongo & Sangeda (2020); Ahmad, et al. (2022); Gladys, et al. (2025); de Souza, et al. (2022); Alkadhimi, et al. (2020); Ferdiana, et al. (2021)
6. Healthcare System Factors	Cost Barriers: High consultation fees at private clinics driving patients to pharmacies Accessibility Issues: Long waiting times, shortage of doctors, or long distances to public health facilities Pharmacy as Primary Care: Community pharmacies viewed as the first point of contact for medical advice	Ntizala, et al. (2020); Barker, et al. (2017); Belachew, et al. (2023); Kotwani, et al. (2021); Gebretekle & Serbessa (2016); Torres, et al. (2020)
7. Interventions and Solutions	Multi-faceted Interventions: Combining educational workshops, regulatory reinforcement, and stakeholder engagement (Action Research) proved most effective in changing behavior Educational & Training Programs: Continuous Professional Development (CPD) focusing not just on clinical knowledge (AMR), but also on soft skills (how to refuse patients) and ethics Regulatory Strengthening: Calls for strict enforcement, “track and trace” systems, and protecting pharmacists from owner pressure. Public Awareness Campaigns: Educating the community to reduce patient pressure and demand for “quick fixes”	Implemented: Ferdiana, et al. (2024). Proposed/Recommended: Barker, et al. (2017); Abubakar & Tangiisuran (2020); Kumar, et al. (2022); Belachew, et al. (2023); Gladys, et al. (2025); Hussain, et al. (2022)

Discussion

Although antibiotics are classified as prescription-only medicines in most LMICs, this systematic review indicate that community pharmacists frequently dispense them without valid prescriptions, driven by multiple interrelated factors. Quantitative synthesis of the included surveys confirms the magnitude of this problem, revealing an average dispensing prevalence of 66.6%, with rates varying from 25.9% to 100% across different regions [17, 36]. This paper synthesizes evidence from 24 studies and identifies seven dominant thematic domains–including economic hardship, weak regulations, professional discretion, and patient demand– that contribute to DAwP in diverse LMICs settings. By incorporating evidence from qualitative, mixed-method, and intervention studies, this work expands upon prior syntheses and provides more comprehensive insights to guide policy and practice.

Pharmacist-related factors, including staffing, qualifications, and professional confidence, further shape DAwP practices. Several studies noted that the absence of certified pharmacists during operational hours or overreliance on informal or inadequately trained dispensers undermines adherence to legal and clinical standards. Even when pharmacists possess awareness of AMR, this knowledge does not necessarily translate into compliant behavior, highlighting the “knowledge–practice gap” also reported in studies from India and Egypt [22, 34].

A substantial knowledge-practice gap remains among community pharmacists. Many practitioners engage in DAwP due to perceived moral obligations toward patients unable to afford physician fees or to avoid conflicts with demanding customers [16, 33]. Evidence from Nigeria and India further demonstrates that regulatory barriers alone are inadequate unless underlying behavioral and socio-cultural factors that normalize non-prescription sales are addressed [23, 26].

Customer expectations and behavioral norms were consistently cited as influencing pharmacist decisions. Patients often associate antibiotics with a rapid and effective recovery, especially for minor infections. In some contexts, patient insistence and the fear of losing clientele have been powerful motivators for DAwP [20, 29]. These findings indicate the need to address both supply- and demand-side behaviors simultaneously through education and regulation. The review’s conclusions confirm that DAwP in community pharmacists was influenced by patient behaviors and system-level issues in addition to pharmacy-centered dynamics [40]. They examined the factors that contribute to inappropriate antibiotic use at the community level and discovered a similar pattern. Both reviews emphasize how barriers to healthcare access, patient demand, and financial hardship all contribute to antibiotic misuse. Long travel distances, a lack of available consultations, and high out-of-pocket expenses are the main reasons why patients frequently turn to pharmacists rather than doctors. These same factors also encourage pharmacists to fulfill requests even in the absence of valid prescriptions [40].

The relationship between education level in the general population and antibiotic misuse has been widely studied, with higher education generally linked to lower odds of inappropriate use, particularly in LMICs and Middle Eastern countries. However, regional variations exist [41]. While this evidence refers to the public rather than pharmacists, it aligns with our review showing that educational background and awareness strongly influence antibiotic-related behaviors. Thus, targeted educational interventions for the community, alongside professional training for pharmacists, are essential to reduce non-prescription antibiotic use and mitigate antimicrobial resistance.

Belachew, et al. (2021) [12] found that business priorities often override professional ethics in community drug retail. Standardizing dispensing methods influenced by competitive pressure and peer behavior suggests that commercial interests often take precedence over public health considerations, along with owner-driven incentives [27, 28]. Due to financial challenges, pharmacists must frequently violate regulations to treat patients and stay in business [16, 28]. In low-resource LMICs, pharmacies usually serve as the closest healthcare provider, increasing tension [17].

The leading causes were economic and contextual. In locations with limited healthcare access and high out-of-pocket costs, pharmacies usually offer primary care, particularly for low-income populations. Our findings align with global research showing that economic hardship compels patients to bypass physician consultations, thereby creating demand-side pressure for non-prescription dispensing [14, 42]. Consequently, pharmacists, particularly in privately owned outlets, often respond pragmatically to patient demand to ensure business survival, highlighting the persistent conflict between professional ethics and financial profitability [43, 44].

Economic viability and systemic healthcare gaps are identified as the most significant drivers of DAwP. In competitive retail markets, concerns about losing customers to competitors and commercial pressures related to expiring inventory frequently take precedence over professional ethics [17, 28]. These economic factors are intensified by the high costs of formal medical consultations and inadequate healthcare infrastructure, which result in community pharmacies serving as primary care providers for low-income populations [17, 32].

Weak regulatory environments were another recurrent theme. Most countries have formal regulations prohibiting the sale of antibiotics without a prescription, but enforcement is often inconsistent. Some pharmacists felt uncertain about legality, while others emphasized a lack of monitoring and sanctions. Regulations that are unclear increase the possibility of noncompliance and promote informal norms [34, 35].

In rural and poor areas, healthcare system shortages can lead to pharmacy-based treatment-seeking behavior. When official healthcare is unavailable, expensive, or inaccessible, pharmacies become primary care providers. Pharmacies’ significant role in curative care emphasizes DAwP as a coping technique rather than a policy violation. Preventing inappropriate antibiotic use, including acquiring antibiotics from community drug retail outlets (CDROs) without a prescription, requires improving access to healthcare in rural and resource-limited areas and reducing barriers such as transportation and bureaucratic hurdles. Universal health coverage (UHC) represents a potential structural approach for ensuring affordable, high-quality healthcare for all community members, decreasing out-of-pocket spending [12].

Multifaceted interventions in several studies demonstrated measurable impact in modifying dispensing practices. A study in Indonesia found a 20.9% decrease in DAwP after applying a combined method of education, peer monitoring, and certification [20]. Limited efforts and a lack of long-term follow-up highlight the necessity for persistent evaluation and scaling up initiatives.

The implementation of proposed regulatory and educational interventions in LMICs faces several significant challenges. A major obstacle is the economic reliance of community pharmacies on antibiotic sales; for many independent outlets, non-prescription dispensing is critical for financial viability and sustaining competitive profit margins [28]. Additionally, enforcement of dispensing regulations is often inadequate, especially in rural regions where regulatory oversight is limited and inspections are infrequent [17, 26]. These issues are further exacerbated by ongoing patient pressure and socio-cultural expectations for rapid recovery, which frequently lead pharmacists to prioritize customer satisfaction over regulatory compliance [15, 16]. Addressing these challenges necessitates practical, technology-based solutions, such as the adoption of ‘track and trace’ systems for real-time antibiotic inventory monitoring and policy reforms to separate pharmacy profits from antibiotic sales volume. Evidence from multi-faceted intervention models indicates that successful outcomes require the integration of these systemic changes with public awareness campaigns to mitigate demand-side pressures [20].

Despite offering valuable insights, the included studies present methodological limitations that must be acknowledged. Numerous cross-sectional surveys relied on self-reported data, raising concerns regarding social desirability bias and limiting behavioral inference. Qualitative studies often lacked reporting of researcher reflexivity, data saturation, and theoretical frameworks, which destabilizes transparency and interpretive credibility. SP studies provided realistic insights into dispensing practices, although they did not explore pharmacists’ motivation. Furthermore, mixed-method and quasi-experimental designs were limited in number and typically lacked long-term follow-up. These limitations highlight the need for future research applying longitudinal, theory-informed, and mixed-method approaches to capture the complexity of DAwP behaviors and to inform sustainable interventions tailored to the local context.

The findings of this review have several important policy implications. Reducing DAwP requires a coordinated, multi-level response involving regulatory enforcement, pharmacist training, community engagement, and systemic healthcare reform. Policies must be context-sensitive and adaptable to the socio-economic and institutional realities of each LMICs. UHC, improved rural healthcare access, and sustained antimicrobial stewardship programs are critical to mitigating inappropriate antibiotic use and shortening the threat of AMR.

Conclusion

This review shows that DAwP continues to pose a significant public health challenge in LMICs, with prevalence rates among community pharmacists reported between 25.9% and 100% (average 66.6%). In addition to the high rates of dispensing, the included surveys consistently reveal a substantial gap between pharmacists’ regulatory awareness and their non-compliant practices, suggesting that knowledge alone does not effectively reduce this behavior.

This systematic review highlights that the practice of DAwP among community pharmacists in LMICs is sustained by a combination of individual, institutional, and systemic drivers. Economic hardship, patient expectations, professional discretion, and gaps in enforcement all contribute to this persistent behavior, even in the presence of awareness regarding antimicrobial resistance. While targeted interventions have shown some promise, their scalability and long-term sustainability remain uncertain.

To meaningfully reduce DAwP and its public health consequences, solutions should consider addressing the structural determinants of antibiotic misuse. This includes improving access to affordable healthcare, ensuring the presence of qualified pharmacy personnel, and fostering accountability within community drug retail systems. Interventions must also align with local contexts, supported by sustained investment in education, regulation, and system-wide antimicrobial stewardship to mitigate the global threat of AMR.

In conclusion, this systematic review of 24 studies conducted in 17 LMICs demonstrates that DAwP is a complex, multi-dimensional issue shaped by economic necessity, healthcare system limitations, and socio-cultural expectations. Recent evidence highlights a substantial gap between knowledge and practice, as professional awareness of AMR is often undermined by business imperatives and patient-related pressures. Effective mitigation requires policy interventions that extend beyond educational initiatives. A shift toward comprehensive strategies, including rigorous regulatory oversight, economic incentives for ethical dispensing, and public awareness campaigns to reduce patient-driven demand, is essential. Addressing fundamental drivers, such as the high cost of formal medical consultations and the commercialization of pharmacy practice, is critical to safeguarding the effectiveness of existing antimicrobials in LMICs.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

FF, WNI and APK contributed to conceptualization, identified the research question, and developed the methodology. FF, WNI and APK contributed to data curation and conducted the screening of articles and analysis of the data. FF prepared the original draft of the manuscript. WNI and APK provided supervision and critically revised the manuscript for important intellectual content. All authors have approved the manuscript to be submitted for publication.

Funding

Universitas Padjadjaran supports the publication fee of this paper.

Data availability

The datasets generated and/or analyzed during the current study are available in the figshare repository, https://figshare.com/s/b89924671a654c348488. Access must be through a formal request to the authors.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.