Pharmacist Prescribing in Saudi Arabia: A Cross-Sectional Study on Readiness, Barriers, and Policy Implications for Healthcare Reform Open Access

Since the inception of healthcare, pharmaceutical and medical care were initially intertwined, with practitioners responsible for both prescribing and dispensing medicines. However, rapid scientific advancements and increasing healthcare complexity led to role divergence. This separation was formalized as early as 120 CE in Europe when German Emperor Frederick II decreed distinct prescribing and dispensing roles, marking the division between pharmacists and physicians [1, 2]. In modern times, the evolution of pharmacy practice has been shaped by the emergence of pharmaceutical care and clinical pharmacy, which have redefined the pharmacist’s role as a key member of the multidisciplinary healthcare team.

These developments have enabled pharmacists to provide patient-centered care, focusing on health promotion, disease prevention, and optimized pharmacotherapy [3]. Pharmaceutical care, as defined by Hepler and Strand, is “the responsible provision of drug therapy for the purpose of achieving definite outcomes which improve the patient’s quality of life” [3]. Despite its theoretical adoption, implementation remains inconsistent globally [4]. Concurrently, pharmacy education has shifted from product-focused to patient-centered models, emphasizing clinical outcomes and interprofessional collaboration [5]. This paradigm shifts positions pharmacists as active participants in designing, implementing, and monitoring pharmacotherapeutic plans, working alongside other healthcare professionals to optimize patient care [6‒9].

Globally, pharmacy practice integrates pharmaceutical care and medicine management, optimizing medication use from procurement to monitoring [10, 11]. This reflects a broader trend toward interprofessional, evidence-based, and patient-centered care, driving healthcare reforms worldwide [12]. The extension of prescriptive authority to non-medical professionals, including pharmacists and nurses, has been implemented in approximately 117 of 216 countries and territories, though only 20 have formal legislation permitting such practices [13]. Among these, the UK exemplifies structured frameworks such as supplementary prescribing – a collaborative partnership between an independent prescriber (e.g., physician) and a supplementary prescriber (e.g., pharmacist or nurse) guided by patient-specific clinical management plans – and independent prescribing, which grants autonomous authority to assess, diagnose, and prescribe within competency boundaries [14]. These models emerged from decades of legislative reforms, beginning with the 1989 Crown Report advocating nurse prescribing and culminating in the 2006 Health and Social Care Act enabling pharmacist independent prescribing [13]. By 2023, over 59,000 nurse prescribers and 19,000 pharmacist prescribers practiced in the UK, demonstrating improved patient access and reduced physician workload [15, 16]. However, initial physician resistance and concerns about diagnostic competence underscored the need for rigorous training and governance frameworks [17, 18].

Internationally, non-medical prescribing (NMP) adoption varies [12]. In the USA, pharmacist prescribing operates under collaborative drug therapy management, where pharmacists adjust therapies via physician-approved protocols, particularly for chronic diseases [19]. Canada’s province-specific models, such as Alberta’s tiered prescribing rights, emphasize collaborative care [20], while Australia pilots pharmacist prescribing in specialized clinics to address rural healthcare gaps [21]. These models highlight common facilitators such as interprofessional collaboration, legislative support, and advanced training and barriers, including physician resistance and uneven policy implementation [22]. Countries with successful NMP integration, such as the UK and Canada, attribute progress to national legislation, standardized curricula, and stakeholder engagement [23].

In Saudi Arabia, the role of pharmacists has evolved significantly in recent years, particularly in hospital settings; however, pharmacist prescribing remains nascent [24]. Clinical pharmacists increasingly engage in direct patient care activities, such as managing anticoagulation clinics, medication therapy management, and ambulatory care clinics [25‒27]. Despite these advancements, the absence of formal legislation creates legal ambiguities and limits role expansion. Ajabnoor & Cooper [28]found that 25% of Saudi hospital pharmacists informally participate in prescribing, primarily under physician collaboration, yet lack legal safeguards. Similarly, Almalag et al. [29] reported community pharmacists’ willingness to prescribe oral contraceptives but identified systemic barriers, including insufficient clinical training and physician opposition [29]. These findings mirror global challenges but are compounded by Saudi-specific dynamics, such as rigid professional hierarchies and gaps in clinical pharmacy education [30, 31].

Despite early concerns about medical resistance [18, 32], pharmacist prescribing is broadly supported by stakeholders, including the public, patients, and healthcare professionals, notably physicians [14, 33‒42]. Substantial evidence highlights its potential benefits, such as improved patient access to medications, enhanced interprofessional collaboration, reduced strain on physicians (particularly in countries with low physician-to-population ratios), and improved better clinical outcomes, and lower healthcare costs, contributing to progress toward sustainable development goals [43‒45]. Furthermore, current data demonstrate that pharmacist prescribers are as safe and effective as traditional medical prescribers [46]. Nevertheless, challenges persist, including training gaps, competency assessments, potential role overlap with physicians and lack of reimbursement [47].

The absence of a legal framework in Saudi Arabia not only hinders the broader adoption of pharmacist prescribing but also exposes pharmacists to legal liabilities, even as demand for expanded services grows. Formalizing pharmacist prescribing necessitates systemic reforms, including legislative updates to permit prescribing, development of clear policies and training programs, and strategies to address interprofessional resistance. Understanding pharmacists’ perspectives is critical to identifying facilitators and barriers to implementation.

This study explores Saudi pharmacists’ readiness for prescribing roles, identifies systemic barriers, and evaluates training needs to inform policy reforms. By examining the attitudes, experiences, and concerns of pharmacists, this study provides valuable insights into the potential for pharmacist prescribing in Saudi Arabia and contributes to the ongoing discourse on the evolving role of pharmacists in modern healthcare systems.

A cross-sectional investigation was conducted from January to July 2018 among pharmacists practicing in Saudi Arabia. Data were collected through a validated questionnaire, initially piloted by 15 pharmacists to refine clarity and feasibility.

The target population comprised registered pharmacists affiliated with the Saudi Pharmaceutical Society (SPS), the sole professional organization for pharmacists, during the study period. Eligibility required active registration with the Saudi Commission for Health Specialties (SCHS), which listed approximately 29,000 pharmacists at the time. However, only 5,000 were SPS members. Using the RaoSoft® sample size calculator (95% confidence level, 5% margin of error), a minimum sample of 380 participants was determined. Recruitment occurred via email invitations.

The study utilized a structured electronic questionnaire adapted from validated instruments in prior research to ensure methodological rigor [48]. The tool was designed using Google Forms® to facilitate digital distribution and data collection. To enhance content validity and reliability, the instrument underwent a two-phase piloting process. In the first phase, the draft survey was reviewed by 10 practicing pharmacists, provided feedback on clarity, relevance, and comprehensiveness. Revisions were made to ambiguous items and formatting inconsistencies based on their input. A final pilot test was conducted to confirm the feasibility of the refined questionnaire before full deployment.

The final questionnaire comprised 62 questions organized into five thematic sections, utilizing mixed response formats: open-ended questions, binary (yes/no) options, and 5-point Likert scales (ranging from strongly agree to strongly disagree). These sections explored demographics, perceptions of clinical pharmacy practice in Saudi Arabia, current prescribing practices, perspectives on expanding pharmacist prescribing (including preferred models and training needs), and finally, the perceived barriers and facilitators to implementing such changes. This structured, mixed-methods approach aimed to provide both quantitative and qualitative insights while balancing in-depth inquiry with respondent burden. Ethical considerations were prioritized, with a consent statement included on the first page of the online survey to inform participants about the study’s purpose, voluntary nature, and confidentiality safeguards. To maintain anonymity while enabling follow-up for incomplete responses, participants were asked to provide optional institutional email addresses.

The finalized survey was distributed electronically to all SPS-registered pharmacists between January and July 2018. Three rounds of email reminders were issued to enhance participation. By the study’s conclusion, 206 responses were recorded.

Ethical approval for this study (H-10-Z-068/1802) was granted by the Research Ethics Committee of Jazan General Hospital, Jazan, Ministry of Health, Saudi Arabia, ensuring compliance with the Declaration of Helsinki and national guidelines. Informed consent was obtained electronically from all participants prior to initiating the online survey. Participants were required to actively select a “Yes” option to confirm their agreement to participate, as approved by the Ethics Committee. Participants were also informed of their right to withdraw at any time without justification.

Data from Google Forms^® were exported to Microsoft Excel^® for organization and cleaned, then analyzed using Stata^® (Version 11.2, StataCorp LP). Descriptive statistics summarized demographic and Likert-scale responses. Categorical variables were analyzed via chi-square tests, with significance set at p < 0.05. Principal component analysis with Varimax rotation and Kaiser normalization was applied to the 26-item barriers/facilitators scale. Factor scores were derived and incorporated into the dataset. Independent t tests compared mean factor scores across demographic groups, while one-way ANOVA assessed differences by geographic region and practice sector.

Despite 3 rounds of email call, a total of 206 pharmacists participated in the study. The majority were male (71.8%, n = 148), with 28.2% (n = 58) female. Nearly half (47.1%, n = 97) were aged 31–40 years, followed by 28.2% (n = 58) aged 21–30 years. Most held a Pharm.D. as their undergraduate degree (88.2%, n = 182), while 11.8% (n = 24) had a B.Pharm. Over half (58.7%, n = 121) reported holding a postgraduate qualification in clinical pharmacy. Respondents primarily worked in institutional hospitals or primary care centers (76.2%, n = 157), with smaller proportions in regulatory/administrative (10.2%, n = 21), academic (7.8%, n = 16), and community (5.3%, n = 11) roles. Geopolitically, 37.9% (n = 78) practiced in the central zone, followed by 25.2% (n = 52) in the south (Table 1).

A strong majority (90.8%, n = 187) agreed that pharmacist specialization in clinical sub-specialties would advance clinical pharmacy practice. Most respondents criticized the lack of a supportive national policy (45.2% disagreed that such policies exist) and insufficient undergraduate training (74.3%, n = 153) to prepare pharmacists for clinical roles. Collaborative practice agreements between doctors and pharmacists were widely endorsed (93.7%, n = 193). Training pharmacy technicians for traditional and basic clinical roles under supervision received substantial support (83.0% and 73.7%, respectively) (Table 2).

Most respondents (87.4%, n = 180) supported granting prescribing rights to pharmacists, contingent on postgraduate training (90.8%, n = 187), competency exams (70.9%, n = 146), and restricting privileges to experienced pharmacists (76.7%, n = 158). Collaborative prescribing with physicians (26.3%, n = 21) and disease-specific protocols (26.3%, n = 21) were preferred models. Despite 63.9% (n = 131) reporting involvement in prescribing decisions, only 29.0% (n = 38) held prescription privileges. Willingness to prescribe was independent of demographics (p > 0.05) (Table 3).

Table 3 highlights that 77.7% of respondents endorsed restricting prescribing to experienced pharmacists, underscoring the need for tiered licensure frameworks. As shown in Figure 1, collaborative models (21.3%) and disease-specific protocols (26.3%) were equally preferred, aligning with global dependent prescribing trends.

Respondents identified pharmacotherapeutics (59.7%, n = 123), medication therapy management (51.9%, n = 107), and patient clinical assessment (49.0%, n = 101) as critical training areas. Only 10.7% (n = 22) felt no additional training was necessary (Table 4).

Key facilitators included improved patient access to care (86.4%, n = 178) and reduced physician workload (88.8%, n = 183). Barriers included physician resistance (77.7%, n = 160), insufficient clinical training (66.0%, n = 136), and inadequate community pharmacy facilities (71.8%, n = 148). Over half (53.4%, n = 110) expressed concerns about commercial conflicts of interest (Table 5).

Principal component analysis revealed three latent constructs underpinning pharmacists’ attitudes toward prescribing, collectively explaining 47.5% of the total variance (Table 6). The first factor, Risks and Clinical Governance (eigenvalue = 7.16, 27.5% variance), encapsulated systemic concerns, including physician resistance to role expansion, perceived gaps in clinical competencies (e.g., diagnostic skills), and ethical conflicts arising from dual dispensing-prescribing responsibilities. This dimension underscores apprehensions about professional accountability and governance frameworks in the absence of formalized prescribing policies. The second factor, Contribution to Patients/Health Systems (eigenvalue = 3.66, 14.1% variance), reflected optimism regarding pharmacist prescribing’s potential to enhance healthcare access, reduce physician workload, and generate cost savings. The third factor, Training/Competency Needs (eigenvalue = 1.52, 5.8% variance), emphasized demands for advanced education in pharmacotherapeutics, clinical assessment, and diagnostic interpretation to ensure safe prescribing practices.

Table 7 presents a comparison of factor scores related to risk perception, contributions to the healthcare system, and training, based on gender and willingness to prescribe. The data reveal that female pharmacists reported a significantly higher mean score for risk perception (0.30 ± 0.92, p < 0.001) compared to their male counterparts (−0.12 ± 1.01, p < 0.001). In contrast, those willing to prescribe exhibited neutral views on the systemic benefits of prescribing (−0.09 ± 0.95, p > 0.05), while hesitant pharmacists showed stronger agreement with its broader value (0.63 ± 1.14, p < 0.001). Regarding training, the scores are relatively similar for both categories. Notably, no significant associations were observed across practice settings, geopolitical regions, or years of experience (p > 0.05 for all factors, Table 8), indicating that attitudes toward prescribing risks, contributions, and training needs are broadly consistent nationwide, irrespective of career stage or workplace context.

The integration of pharmacists into prescribing roles represents a transformative opportunity to address healthcare workforce shortages and improve patient outcomes. This study examined the readiness, challenges, and systemic barriers to pharmacist prescribing in Saudi Arabia, contextualizing findings within global trends. The results reveal a complex landscape of optimism, challenges, and systemic barriers surrounding pharmacist prescribing in Saudi Arabia, mirroring global trends while reflecting unique regional dynamics.

A significant majority (87.4%) of Saudi pharmacists in this study expressed a willingness to assume prescribing responsibilities if supported by appropriate training and enabling legislation. This finding resonates with similar local views and parallels studies in Nigeria, where over 75% of surveyed pharmacists advocated for expanded prescribing authority to improve healthcare access, despite reservations about diagnostic competence [28, 48]. This enthusiasm aligns with international shifts toward expanding pharmacists’ clinical roles to alleviate physician shortages and improve patient care.

For instance, in the UK, pharmacist prescribing has been institutionalized through structured models like supplementary prescribing under physician collaboration and independent prescribing using protocols for chronic diseases. Since 2006, registered independent prescriber pharmacists in the UK have reduced physician workload, patient wait times, and improved chronic disease management by allowing more time for consultations [34, 38, 49, 50]. Similarly, qualified Canadian prescribing pharmacists routinely manage complex therapies in critical care, oncology, palliative care, and surgery [51, 52]. In the USA, collaborative drug therapy management by clinical pharmacists with prescribing authority has played a key role in delivering high-quality, cost-effective chronic disease and medication management [53, 54]. Likewise, in Australia and New Zealand, pharmacist prescribing is considered vital for managing drug-related problems, improving health outcomes, and reducing health inequities [55, 56].

In Saudi Arabia, a similar trend is emerging, with the preferred prescribing models among respondents in this study being collaborative practice with physicians and protocol-driven approaches (26.25%). This mirrors the dependent prescribing models seen in the aforementioned countries. However, unlike these countries, Saudi pharmacists currently lack legal authority to prescribe, and concerns about adequate training and professional acceptance persist.

This study, consistent with Ajabnoor and Cooper [28], confirms that many Saudi hospital pharmacists engage in prescribing (primarily collaborative) and are confident in their abilities. However, this exposes them to legal risks due to current Saudi regulations. Furthermore, female pharmacists in this study reported significantly higher risk sensitivity (p < 0.001), potentially reflecting systemic challenges such as unequal access to clinical training opportunities or workplace hierarchies observed in Saudi healthcare settings. However, willingness to prescribe did not differ by gender (p > 0.05), suggesting that risk perception does not inherently deter female pharmacists from advocating for expanded roles but may necessitate targeted support mechanisms. Formalizing pharmacist prescribing is thus crucial, requiring systemic reforms including legal authorization, comprehensive policies, and gender-sensitive training to address risk perception disparities. These reforms align with international efforts to harmonize professional confidence and accountability. Saudi Arabia’s lack of formal NMP policies creates a gap between pharmacists’ readiness and system capacity, mirroring pre-reform contexts like Canada where legislative ambiguity hindered role expansion [12, 57‒59].

To effectively integrate pharmacists as prescribers within Saudi Arabia’s healthcare system, a comprehensive strategy informed by global best practices and tailored to local needs must be implemented. Central to this strategy is curriculum reform within pharmacy education. Reforms in pharmacy education in the UK, Canada, and other countries that have legislated pharmacist prescribing represent a major shift toward enabling this practice [60]. Nearly three-quarters (74.3%) of Saudi pharmacists considered the current curriculum insufficient, citing limited experiential learning. Redesigning curricula to emphasize direct patient care, interprofessional collaboration, and experiential learning will produce confident and competent pharmacists ready to meet the evolving needs of healthcare systems [61]. Expanding postgraduate clinical pharmacy programs, which provide real-life clinical experiences in clinical examination and pharmacotherapeutic skills, offers another solution. Specialization through specialized certificates with hands-on training or postgraduate master’s or professional training, such as residency or fellowship programs, could enhance preparedness for advanced roles. This could alleviate pharmacists’ self-identified limitations in this study, such as inexperience with diagnosis and inadequate clinical examination skills.

Another dominant barrier identified in this study was physician resistance, reported by 77.7% of respondents. Additionally, 29% of respondents acknowledged that prescribing without legal authorization creates ethical and legal risks. This, along with the physician resistance, reflects cultural hierarchies that conflate prescribing with diagnostic authority, similar to dynamics observed in the UK, where expanded pharmacist roles were perceived as encroaching on medical authority [18].

Despite the barriers, significant facilitators for pharmacist prescribing were identified in this study, such as improved patient access (reported by 86.4% of respondents) and optimized physician workloads (88.8%), which align with global evidence. For instance, evidence highlighted that pharmacist-led interventions in primary care settings in the UK significantly improved access to medications and reduced waiting times for patients, especially those with chronic conditions like diabetes and hypertension [34, 38, 49, 62]. In Canada, pharmacist prescribing services were both highly accessible and beneficial in improving access to medicines [63] and resulted in a clinically important and statistically significant improvements in managing stroke [44], hypertension [64], and other conditions [65].

This study, like any research, has strengths and limitations that are important to consider when interpreting its findings. The study addresses the critical and underexplored issue of pharmacist prescribing in Saudi Arabia. This topic is increasingly relevant given the global trend toward expanding pharmacists’ roles to address physician shortages and improve patient care. The findings are particularly timely as Saudi Arabia undergoes healthcare reforms aimed at enhancing access and optimizing healthcare delivery.

The study used a robust structured questionnaire to understand pharmacists’ perspectives on prescribing in Saudi Arabia. Validated instruments and a two-phase pilot ensured data reliability. A diverse pharmacist sample across practice settings and regions strengthens the generalizability of findings. The study assured the global similar systemic barriers (e.g., lack of legislation, training needs) and facilitators (e.g., improved patient access, reduced physician workload). These insights are crucial for policymakers implementing such programs. By contextualizing findings within global trends and successful models, the study guides Saudi Arabia in adopting best practices.

However, the study has limitations. First, the sample’s heavy representation of hospital pharmacists (76.2%) may restrict the generalizability of findings to community pharmacists, who often serve as the initial point of contact for patients. This is particularly relevant given that 71.8% of the surveyed pharmacists reported inadequate clinical facilities for patient consultations. Second, the cross-sectional design employed prevents the establishment of causal relationships [66]. While pharmacists showed willingness to prescribe, the study cannot predict their actual behavior following removal of legal and systemic barriers. Third, the reliance on self-reported data introduces the potential for response bias [67]. Furthermore, the study did not include the perspectives of other healthcare professionals such as physicians, whose resistance is a known impediment. Although the study acknowledges the absence of legal frameworks for pharmacist prescribing, the study could have more thoroughly investigated a critical area warranting further scrutiny the ethical and legal risks associated with unauthorized prescribing.

Another key limitation is the low response rate (206/5,000 SPS members), despite follow-up reminders, which may compromise representativeness and introduce non-response bias. Community pharmacists were markedly underrepresented (5.3% [11/206] vs. 30% nationally), whereas female respondents (28.2%) mirrored their proportion in the national pharmacist workforce (24%) [68]. This discrepancy in practice-setting representation for community pharmacist limits generalizability. Contributing factors include survey fatigue, time constraints, and reluctance to engage with policy-sensitive topics [69]. Nevertheless, low response rates do not inherently invalidate findings [70], especially that a post hoc power analysis confirmed sufficient statistical power (80%) to detect medium effect sizes for primary outcomes affirming the sample’s adequacy despite its size [71]. Additionally, uneven response distribution across geopolitical regions may introduce bias. Future studies should employ oversampling strategies to ensure balanced representation of underrepresented groups and regions [72]. Such approaches would enhance insights into localized barriers, including disparities in resource access, training opportunities, and scope-of-practice variations, while proportional sampling across practice settings would strengthen validity.

Despite these limitations, the study offers actionable recommendations for policymakers, including curriculum reform, expanded postgraduate training, and legislative changes to formalize pharmacist prescribing. These recommendations, grounded in local findings and global best practices, are highly relevant for Saudi Arabia’s evolving healthcare system, as is the case in Netherland, Italy and other countries [41, 42, 73]. The study also sets the stage for future research, particularly longitudinal studies and pilot programs to evaluate the implementation of pharmacist prescribing.

By examining pharmacist prescribing in a Middle Eastern context, the study contributes to the global body of knowledge on this topic. It highlights both the universal challenges (e.g., physician resistance, training needs) and unique regional dynamics (e.g., cultural hierarchies, legal constraints) that influence the adoption of pharmacist prescribing.

Saudi pharmacists demonstrate a readiness to embrace NMP roles, contingent on systemic reforms. This study provides critical insights for Saudi Arabia and other countries considering similar reforms, offering a balanced perspective of the opportunities and challenges associated with expanding pharmacists’ roles in healthcare. Building on these findings, a follow-up study is proposed for 2026–2028 to evaluate shifts in pharmacist practice post-transformation era in Saudi Arabia and the integration of recent graduates trained under revised clinical curricula. This longitudinal design will assess temporal interprofessional trends and the impact of policy changes.

The author extends his appreciation to the Saudi Pharmaceutical Society for distributing the survey link three times during the study period. The author also extends appreciation to all participated pharmacists.

Ethical approval for this study (H-10-Z-068/1802) was granted by the Research Ethics Committee of Jazan General Hospital, Jazan, Ministry of Health, Saudi Arabia, ensuring compliance with the Declaration of Helsinki and national guidelines. Informed consent was obtained electronically from all participants prior to initiating the online survey. Participants were required to actively select a “Yes” option to confirm their agreement to participate, as approved by the Ethics Committee. Participants were also informed of their right to withdraw at any time without justification.

The author reports no conflict of interest.

The author declares that no funds, grants, or other support were received during the preparation of this manuscript.

The whole work – conceptualization, methodology design, data collection, management, and analysis, as well as manuscript preparation – was performed by the author.

The datasets used and/or analyzed during the current study are available from the author upon reasonable request. Restrictions apply to the availability of these data due to privacy and ethical considerations.