Iranian Journal of Pharmaceutical Research (2018), 17 (3): 1105-1115

Received: September 2016

Accepted: May 2017

Original Article

Main Factors Affecting Physicians’ Prescribing Decisions: The Iranian

Experience

Sayed Hesam aldin Sharifniaa, Mehdi Mohammadzadeha*, Gelareh Arzanib, Jamshid Salamzadehc,
Sayed Abolfazl Abolfazlia, Alireza Zalid and Ali Reza Khoshdele

Department of Pharmacoeconomy & Administrative Pharmacy, School of Pharmacy,

a

Shahid Beheshti University of Medical Sciences, Tehran, Iran. bMofid Children’s Hospital,
Shahid Beheshti University of Medical Sciences, Tehran, Iran. cDepartment of Clinical
Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
d
Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences,
Tehran, Iran. eFaculty of Medicine, AJA University of Medical Sciences, Tehran, Iran.

Abstract

Prescription decision making is a complicated phenomenon influenced by many factors

including drug strength, the patient’s context, prescriber characteristics, health facilities, payment
type, and pharmaceutical marketing. To evaluate the associations between each influenced factor
and drug prescription method of Iranian physicians, we conducted an exploratory research,
utilizing a questionnaire as quantitative research instrument. A sample of 460 physicians was
asked to fill out the questionnaire, yielding 84% response rate. The statistical analysis from the
collected data demonstrated that Iranian physicians mostly paid attention to the payment type,
the patients’ individual factors and the products’ characteristics while prescribing a medicine.
In addition, it was revealed that marketing expenditures did not have a high influence on the
physicians’ demand for pharmaceutical products in Iran. The obtained results may be useful for
Iranian pharmaceutical companies’ marketing strategy planners as well as the patients who are
the exact consumers of the prescribed medicines.

Keywords: Prescription behavior; Pharmaceutical Marketing; Consumer; Payers’ factors;

Products’ factors; Environmental factors.

Introduction and competitive and the immense significance

of Pharmaceutical Companies in a country›s
There is an ever-growing interest shown in economy is evident. Indeed, that is the reason
studying physicians’ decision making and the why Pharmaceutical companies are among the
factors affecting it, lately. The primary reason most evaluated and analyzed organizations in
is that physician valuating consumption of business today.
more than 10 percent of gross domestic product However, the utilized marketing strategies in
(GDP) of most developed nations to healthcare is pharmaceutical industries are hugely different
highly integrated to pharmaceuticals. The global from those employed in other markets. Unlike
market of pharmaceutics is large, growing, the traditional buying decision process, the
influencers, gatekeepers and deciders in the
* Corresponding author: prescription medicine market are physicians
E-mail: m_mohammadzadeh@sbmu.ac.ir and the patients are the buyers and consumers
Sharifnia S H et al. / IJPR (2018), 17 (3): 1105-1115

(4). Earlier studies statistically illustrated the of prescribed drugs in Iranian pharmaceutical
significant positive effects of detailing and free market is inevitable. Thus, this present research
drug samples as the two central components attempts to empirically identify the major factors
of pharmaceutical marketing practices on that influence physicians’ behavior in prescribing
the number of new prescriptions issued by medicine to provide a holistic picture of drug
physicians (5). Other studies on pharmaceutical prescription and expand the horizons of existing
marketing also identified the key role of other research in physician prescribing behavior in
marketing tools such as the relationship of Iran. Hopefully, the weight of each influenced
pharmaceutical sales representatives with factors illuminated from this study will help
doctors, advertising, marketing research, the Iranian pharmaceutical companies to work
public relations, and distribution on physicians’ in emergent pharmaceutical markets and these
prescription behavior (4, 6). Furthermore, a very responsiveness estimates can then be used to
important phenomenon in prescription behavior appropriately target physicians by allocating
which should not be neglected is the continuity detailing resources across physicians more
in prescribing the same company’s drugs effectively.
defined as prescription loyalty which could be
derived from positive experiences gained by Conceptual Framework and Methods
a physician during the treatment phase after From the above literature review, it is evident
repeated prescriptions (7). Aside from marketing that the phenomenon of prescription is diffused
factors (advertising, sales representatives, drug and so many factors, including the prescribers
expenses, and trade fairs) and professional (physicians), the consumer (patient) and the
factors (journals, prescription loyalty, opinion payer (insurance, state or user), are involved in
leader influence, and recommendations the process (10). In Iran, it is mostly the doctors
by colleagues), factors regarding patient who specify the medicines they prescribe.
characteristics, patient treatment history, Consequently, the decision is not made neither
comorbidity and payer type have obvious effects with the patient nor with the payer. However, the
on physician choice behavior, as well. Due prescribers will make their decisions based on
to the serious consequences and side-effects the following factors:
that might be made by prescribing the wrong
products, physicians follow some treatment • Patients’ influence (profile such as age,
guideline focused on the importance of patient race, gender; co-morbidity and treatment
comorbidity and inherent characteristics such as history)
age, gender, and race to choose the best available • Physicians’ experience and product
treatment for the patients (8). valuation
Taking all the above factors into account, it • Products’ influence (safety, efficacy, side
can be estimated that physician’s decision making effect, cost)
on prescribing medicines has components of • Marketing activity of pharmaceutical
both consumer and industrial type. Therefore, strategies (samples, details, advertising)
it is a hybrid buying situation. Although the • Payers’ influence (insurance, managed
decision on which medicine will be prescribed care, …)
should primarily depend upon scientific • Environmental factors (relationships with
criteria, personal and social values as well as pharmacists and coworkers, seminars
economic factors may play a role, especially and congresses, access to medicine, work
when it is about diseases that may be treated place, …)
by a few alternative medicines with negligible
differences. Regarding the fact that supply of In order to fully consider all the influence
non-prescription drugs is tightly restricted by factors on the phenomenon of medical
Iranian Food and Drug Organization (IR-FDO), prescription, five theoretical constructs,
equivalent to the American Food and Drug containing patients’ related factors, products’
Administration (FDA), the huge importance related factors, payers’ related factors,

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 H3. Drug prescriptions are affected by Marketing and Pharmaceutical Companies' strategies
H4. Drug prescriptions are affected by the patients’ related factors
H5. Drug prescriptions are affected by the payers’ related factors (Figure 1)

Main Factors Affecting Physicians’ Prescribing Decisions: The Iranian Experience

Figure 1. Influenced Factors on Prescription as Decision Making.

Figure 1. Influenced Factors on Prescription as Decision Making.

A quantitative
environmental approach
factors and with the survey
marketing and method support was
demographics utilized
were to examine
nominal the scale
and ordinal five
strategies of pharmaceutical companies, were and the other 54 questions were formulated
previously mentioned factors influencing prescribing decisions. A structured questionnaire in
developed within a framework. Likert scale, ranging from 1- strong agreement
adapted fromthe
Subsequently, modeling based
following on the researched
hypotheses are totheoretical
5- strongreferences was made
disagreement. The to collectofdata.
validity the
drawnThebased on the relationship
questionnaire between
was constructed on 63 the questionnaire
questions was measured
in which 9 questions in a sub-group
about demographics wereof
physicians’ drug prescription behavior and the ten Iranian doctors pursuing the aim that the
influenced factor discussed above: content of the questionnaire could be correctly
understood. Moreover, the reliability of the
H1. Drug prescriptions are affected by the questionnaire, which examines the consistency
environmental factors of a concept measure, was assessed. The
H2. Drug prescriptions are affected by the reliability of the questionnaire was broadly
products’ related factors satisfactory as the Cronbach’s Alpha coefficient
H3. Drug prescriptions are affected by was totally exceeded 0.6 and some of them have
Marketing and Pharmaceutical Companies› reached to 0.9.
strategies In an attempt to select study respondents
H4. Drug prescriptions are affected by the randomly from 39747 available Tehran’s
patients’ related factors physicians from all geographic regions, all
H5. Drug prescriptions are affected by the specialties and all age groups, a two-stage
payers’ related factors (Figure 1). cluster sampling technique was used. In the first
stage, from 22 Tehran’s regions, 6 regions were
A quantitative approach with the survey randomly picked. Afterwards, in each region,
method support was utilized to examine the 3 hospitals were chosen among the overall 84
five previously mentioned factors influencing hospitals available in these 6 regions.
prescribing decisions. A structured questionnaire Among 460 questionnaires distributed to all
adapted from modeling based on the researched doctors working in the selected hospitals, 385
theoretical references was made to collect questionnaires were correctly answered which
data. The questionnaire was constructed were further investigated statistically. Descriptive
on 63 questions in which 9 questions about statistical analyses from the collected data were

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Sharifnia S H et al. / IJPR (2018), 17 (3): 1105-1115

Table 1. Descriptive Analysis of Demographic Characteristics.

firstly performed. In addition, in this study,

10.9%

10.3%
>16

42

>20
structural equation modeling (SEM) analysis

40
Medical Review (hours per week)

using PLS with reflective indicators in Smart-

12.1%
12-16

PLS 2.0 was utilized for instrument validation

46

15-20

4%
and model testing.

15
Years of Experience
18.4%
8-12

71

Analysis and Results

10-15

8.6%
33
Descriptive analysis of demographic
22.4%
4-8

86

characteristics of participants
Table 1 summed up the descriptive statistical

17.2%
5-10

66
36.2%

analysis of the collected data from 385

139
1-4

participants. Based on the obtained results, the

greater number of participants were females and
59.8%
230
1-5
23.7%`

between the age of 25 and 30, with the percentage

>16

91

of 53.6% and 46.4%, respectively. In terms of

Working Hours Per Day

educational level, specialists account for the

12-16

9.2%

Doctorate
35

12.1%

most common respondents (228 participants)

Post-

46

with approximately twice the numbers of

41.4%
8-12

159

general practitioners and 5 times more than

Education Level

post-doctorate participants. A majority of the

Specialist

59.2%
17.8%

228

respondents (59.8%) had been engaged in the

4-8

69

medical profession for one to five years and

58.6% of the participants tended to study less
1-4

8%
31

Practitioner

than 8 h a day. Interestingly, the participants were

General

28.7%
111

so hard-working that more than 74% of them

Places
Other

4%
15

worked more than 8 h a day. Among the possible

work places available for the sample physicians,
Hospital

it could be seen that 48.3% of the doctors were

Private

4.6%

Male

46%
177
18

associated with private clinics while 24.1%

Gender

of them were affiliated with governmental

Governmental

Female

hospitals.
54%
208
Hospital

24.1%
93

Descriptive analysis of research variables

Work Place

As illustrated in the Table 2, all participants

7.5%
>50

29

agreed highly with the role of products’ factors

Governmental

in prescription as it showed a mean of around

Clinic

6.3%

4.1 out of 5 scale with a low standard deviation

24

14.9%
40-50

57

of 0.5. However, all five factors demonstrated

Age (year)

as effective (means over 2 out of 5) with the

28.2%

differences distributed evenly as the standard

31-40
Private

48.3%
Clinic

108
186

deviation was relatively low in all the cases.

In terms of assessment of the normality
Private

49.4%

of the data, which is a prerequisite for many

25-30
12.6%
Office

190
49

statistical tests as normal data is an underlying

assumption in parametric testing, Kolmogorov-
Characteristics

Characteristics

Smirnov test was utilized. All five categories

of the Sample

of the Sample
Demographic

Demographic
%Frequency

%Frequency

resulted in favorable normal hypotheses with the

Frequency

Frequency

significance value above 0.05.

Group

Group

With respect to the reliability of each single

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 Main Factors Affecting Physicians’ Prescribing Decisions: The Iranian Experience

Table 2. Descriptive Analysis of Research Variables and Kolmogorov-Smirnov Test Result.

Quarter The
FFResearch Standard Normality
Mean* Median* Z-value Significance
Variables Deviation* First Second Third Result
Level
Patients’
3.644 3.667 0.633 3.200 3.667 4.025 0.651 0.79 Normal
Related Factors
Products’
4.083 4.059 0.522 3.765 4.059 4.471 0.930 0.353 Normal
Related Factors
Marketing and
Pharmaceutical
2.252 2.233 0.685 1.733 2.233 2.667 1.099 0.179 Normal
Companies’
Strategies
Environmental
2.619 2.571 0.754 2.000 2.571 3.000 1.001 0.171 Normal
Factors
Payers’ Related
3.316 3.200 0.889 3.000 3.200 4.000 0.540 0.933 Normal
Factors
*Sample Size = 385

concept revealed on table 3, the extracted mean t-value and the standardized coefficients (β) of
variance and reliability obtained from each the structural equation modeling. As summarized
factors were above 0.5. In addition, in order in Table 5, t-value and β obtained for products’
to evaluate the reliability of the questionnaire, related factors, patients’ related factors and
the composite reliability and Cronbach’s Alpha payers’ related factors would be counted as
indexes were calculated. As both indexes were meaningful either if P < 0.05 or P < 0.01. In the
Figure out to be above 0.7, the reliability of the lights of the findings of this studies summarized
measuring instrument was proved. in the integrated model, products’ related factors,
Table 4 summarized the inter-correlations and patients’ related factors and payers’ related
reliabilities of the study variable in the structural factors have got the most influence on drug
equation model. As is shown in Table 4, the prescription of the Iranian doctors.
reliabilities of all the variables, ranged from
0.87 to 0.71, are quite acceptable for research H1. Drug prescriptions are impacted by the
purposes. environmental factors.
Goodness of fit (GOF) index was also assessed As is shown in Table 5, t-value for this
revealing the discrepancy between the statistical hypothesis was 0.797 which was not in the
model and the data at hand. As the obtained GOF acceptable range of P < 0.05 (|t |> 1.96). As a
index (0.646) was over 0.5, all models fitted result, the hypothesis is rejected with 95% of
satisfactorily and the main hypotheses of the certainty as it is not statistically meaningful.
research was thus confirmed. Our result was in contrast with previously
Analysis of the overall coefficient of studies which mentioned the direct role
determination showed adequate fit indices of the information source and evidence in
following limits propose by Mulaik et al. (10). prescribing decisions. Smith et al., in one of
Higher than 0.5 coefficient index represents the the most significant volumes on pharmaceutical
efficacy of the study’s hypothesis and in this marketing qualifies their approach to marketing
study it shows that 77% of changes in doctor’s as environmentalist, thus highlighting the
decision making during drug prescription could importance of environmental factors in
be explained by the study’s five variables. marketing in pharmaceutical industry. He came
to the conclusion that modern marketing is
Results and Discussion value-driven, where the consumers and other
constituents of the environment are regarded
The theoretical models were estimated by as partners, and marketing itself is focused on

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Table 3. Reliability Indexes of the Study.

Composite Coefficient of Cronbach’s
Latent Varient AVE AVE GOF*
reliability Determination Alpha R2
Prescription as decision
0.773 0.766 0.77 0.662
making

Environmental factors 0.512 0.826 0.762

Products’ related factors 0.529 0.947 0.940

0.784 0.824 0.646
Marketing and
Pharmaceutical 0.540 0.915 0.901
companies’ strategies

Patients’ related factors 0.610 0.939 0.925

Payers’ related factors 0.725 0.929 0.905

*GOF = Goodness of Fit

creating and maintaining long-term relationships might be explained by the recent changes in
with the target environment, surpassing a medical regulations in Iran. Since 2013, the
relationship based on a simple transaction (11). government has legislate a rule in healthcare
The impact of social interactions and peer effects system restricting the open pharmaceutical
in the context of physician prescription choices market with the aim of supporting the Iranian
was also studied by Nair et al. (12). Normally, pharmaceutical companies, reducing the cost of
most physicians attend workshops, seminars, and healthcare services and monitoring the illegal
conferences where they are advised to prescribe imports of drugs and equipment. According
a particular company’s drugs. The physicians to this legislation, all governmental hospitals
also meet their peers and interact with them have been required to substitute the prescribed
about their experiences. Nair et al. explained pharmaceutical product to the cheapest available
that the behavior of active research specialists, Iranian generic when the prescribing physician
or “opinion leaders,” in the physician’s opposes it. If a physician vetoes the substitution
reference group had a significant influence on for medical reasons, a committee will
the physicians’ prescription behavior. Moreover, investigate the reasons and decide what changes
Al-Areefi et al. (13) mentioned the key role of should be considered. For the pharmaceutical
medical representatives as the most common products and equipment that does not have
information source associated with the decision to an Iranian substitution, there is a reference of
prescribe newly marketed drugs, while patients, confirmed brand-named products from which
colleagues, and pharmacists also play a role in the governmental hospitals can decide to use.
informing physicians about new or alternative Obviously, one significant consequence of
drugs. Besides, the age of the physicians should the recent legislation is reducing the number
also be taken into account. Cheraghali et al. (26) of pharmaceutical companies and available
concluded that there is a substantial influence drugs. Besides, there is a rising competition
from gender of prescribers on prescribing between Iranian drug companies to grow in this
pattern. The study showed that male prescribers available competitive pharmaceutical market by
are more restricted on rational prescription producing more high quality generic substitution
of injection. Therefore, it is suggested that in to eliminate the needs of importing drugs. In
order to maximize effectiveness of corrective addition, the huge role of medical representatives
interventions, they should be tailored according in providing commercial sources of information
to the gender of the prescribers. which influences the physicians’ prescribing
The contrast observed in our study behavior diminished to a large degree as the

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 Main Factors Affecting Physicians’ Prescribing Decisions: The Iranian Experience

Table 4. Intercorrelations among the Measured Variables.

Latent Varient 1 2 3 4 5 6

Prescription as decision making 0.879

Environmental factors 0.571 0.715

Products’ related factors 0.580 0.478 0.728

Marketing and Pharmaceutical companies’ strategies 0.704 0.393 0.515 0.735

Patients’ related factors 0.595 0.473 0.548 0.378 0.781

Payers’ related factors 0.397 0.248 0.383 0.223 0.388 0.851

medical representatives could visit the physicians Like some well-known companies, including
with difficulties and their products would not be Novartis, AstraZeneca, Sanofi, some Iranian
purchased and substituted to the ones in use so pharmaceutical companies have tried to
easily. enhance their corporate brand equity through
their marketing communications which can be
H2. Drug prescriptions are impacted by the resulted in corporate reputation as the extent
products’ related factors. to which the company is trusted, admired, and
According to the data, this hypothesis was respected by physicians. If physicians assume
accepted due to the obtained t-value (3.284) that the company’s reputation is well deserved,
which is higher than 1.96. As a conclusion, they tend to always prescribe its drugs based on
products’ related factors, such as its safety, the company’s history of effective drugs (17).
efficacy, bioavailability, and so on were
evaluated to have a meaningful and positive H3. Drug prescriptions are impacted by
relationship with doctors’ prescription habits. It Marketing and Pharmaceutical Companies›
can be logically hypothesized that a physician strategies.
will firstly take the product efficacy in to account It can be seen from Table 5 that this hypothesis
in order to prescribe a medicine. was also rejected showing a t-value of 1.043
It can be obviously explained by the fact which was lower than 1.96. So, Marketing and
that a drug is an extremely tangible product and Pharmaceutical Companies› strategies factor did
as such, the core and augmented constituents not have a reasonable relationship with doctors’
would be strongly studied (14). The core prescription behavior. These findings are in
product reflects the medicine’s efficacy, usage, contrast with the well documented huge impacts
side effects, and contraindications. Likewise, the of pharmaceutical marketing on educating and
augmented constituent comprises a vast array of broadcasting of new medical treatments.
add-value services, i.e., the firm’s support with For a pharmaceutical company, physicians’
scientific evidence from clinical studies, the and patients’ judgments or decisions about the
interaction and service from the firm’s detailer, company’s products defines as success. Having
in terms of other secondary add-value benefits the aim of conveying integrated messages,
(11, 15). An exploratory four-firm market-share pharmaceutical companies provide a vast array
study in 1996 found that the sales quantity of the of services to all concerned parties utilizing
pharmaceutical firm is hugely affected by the various methods such as personal selling,
product quality (measured by efficacy, dosage which seems to be the most powerful in many
forms, side-effect profiles, and indications for marketing studies (18, 14), free samples and
which the product had received FDA approval) gifts including financing for domestic and
(16). There is a significant level of corporate international conference participation, travel
reputation for some corporate brands among and accommodation, medical education, meals,
all its stakeholders in pharmaceutical industry. and small gifts (19, 20), advertising (in journals

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Sharifnia S H et al. / IJPR (2018), 17 (3): 1105-1115

Table 5. Structural Equation Modeling Results.

Independent Coefficient of Hypothesis
Dependent Variable β t-value Relationship
Variable Determination Status

Environmental
0.034 0.797 0.770 Rejected Non reasonable
factors (H1)

Products’ related
0.167 3.284 Accepted Direct
factors (H2)

Marketing and
Prescription as Pharmaceutical
0.085 1.043 Rejected Non reasonable
decision making companies’
strategies (H3)

Patients’ related
0.351 5.614 Accepted Direct
factors (H4)

Payers’ related
0.500 6.346 Accepted Direct
factors (H5)

|t|>1.96 Significant at P < 0.05; |t|> 2.58 Significant at P < 0.01.

to reach physicians, and in other media to not just because of the medical representatives’
reach consumer–called Direct-to-Consumer persuasive information to physicians. Due to
advertising), and coupons (both physician and the fact that amongst the products with equal
patient coupons) (6). Although the assumption quality and efficacy, the cheapest one is selected
that physicians’ prescribing behavior is only based by governmental hospitals; pharmaceutical
on the rewards offered by the pharmaceutical companies have to change their policies and
companies seems unreasonable, the rewards cut their additional expenses to reduce their
certainly help physicians to remember the products’ total cost. In this way, their chance
company brands resulting in higher benefits to of election in the governmental hospitals’
the company (19). Gonul et al. described the formulary, which is extremely profitable for
anecdotal evidence from physician discussions pharmaceutical companies, will be enhanced.
that even with similar main ingredients in
competitive brands, physicians avoid prescribing H4. Drug prescriptions are impacted by the
another brand for refills in order to keep the patients’ related factors.
possible placebo effects of the original brand Based on the data estimated, t-value of this
which has already worked for the patient. As a hypothesis was 5.614 which was markedly
result, higher consumption of the companies’ higher than 1.96.
products would be resulted (20). As a result, with 95% of certainty, the
However, the contrast findings from this hypothesis was accepted. The relationship
study might be associated to the new Iranian between the patients’ related factors and
governmental legislation in healthcare system. doctors’ prescription was counted as positive
As previously mentioned, this legislation aims and meaningful. Showing a high β could indicate
to diminish the healthcare expenses, widespread that this hypothesis was one of the most effective
healthcare services, and strengthen Iranian factor in doctors’ prescription.
pharmaceutical companies. Reaching these Patients are considered to be at the center
goals, high restrictions are provided to use the of the prescribing process by physicians and
cheapest generic products or preferred drugs on the outcome of the treatment on patients’
the formulary, which are covered by insurances, health is the physicians’ main concern. Al-
in governmental hospitals. The formulary Areefi et al. reported that patient variables,
drugs are chosen regarding to their efficacy and including the patient’s clinical condition, failure
characteristics after passing several steps and of current therapy, financial situation and

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 Main Factors Affecting Physicians’ Prescribing Decisions: The Iranian Experience

ability to purchase, and patient’s compliance, expensive treatment among alternatives with
had powerful influence on the physicians’ less concern in comparison to the patients who
prescribing decisions. Physicians will prescribe did not have insurance (24). Besides, previous
different medications regarding the severity of researches have shown that pharmacists have an
the patients’ conditions. For example, a more incentive to dispense the uninsured prescription
effective drug will be prescribed for patients in with lower priced generic drugs as offering
ICU service in comparison with other patients lower prices not only resulted in patients’
(13). Besides, physician’s price sensitivity more satisfaction with the prescriber and the
may vary significantly regarding the patient pharmacist, but also resulted in patients’ more
income class. The physicians acting as agents compliance to the medication (25).
for low-income patients and consider for lower In Iran, insurances provide the cost of the
price among medicines of similar efficacy for cheapest available generic drugs and equipment
a given medical treatment. Likewise, patient’s and Iranian pharmacists have required to
psychological reaction to the product usage substitute the prescribed medicine to the
or efficacy may also mediate the physician’s cheapest available generic when neither the
prescribing behavior (14). Researches have prescribing physician nor the patient opposes
shown that previous use of an effective it. Patients who oppose substitution have to pay
pharmaceutical product promotes the prescribing the difference in price themselves. Regarding
of that product as refills. Unless available reports the fact that brand-name products are mostly
of some adverse side effects from the patients, not covered in insurances and their price is
the physicians’ usually do not tend to change the much higher than the cheapest generic drugs,
prescribed drugs. Besides, patients also often are patients show less desire to purchase brand-
not in favor of changing the medicines’ brand. It name products in comparison with the generic
is mostly obvious in older patients and patients ones. As a result, the Iranian insurances help
with chronic disease who have less favorable to strengthen the Iranian pharmaceutical
attitudes toward changing the brands even if the companies by covering the price of the generic
prescription is not covered in drug insurance (13, drugs instead of the brand-name pharmaceutical
21, 22). Thus, in terms of subjective knowledge, products. Moreover, the two significant roles of
it could be interpreted that the more the doctors’ the payers on Iranians’ physicians could not be
knowledge about the patients’ condition, the neglected. On the one hand, payers try to induce
more satisfaction would be resulted by the the physician to prescribe Iranian generic drugs
advised medical prescription. which are cheaper or to prescribe the preferred
drugs which are listed on the formulary for which
H5. Drug prescriptions are affected by the the payers have a favorable contract with the
payers’ related factors manufacturer and on the other hand, payers have
Payers’ related factor was also a hypothesis some control over the physician directly since
which was accepted with 95% of certainty they pay the physician fees and decide which
according to the high t-value of 6.346. The physicians remain in or out of the preferred
hypothesis was actually evaluated as the most network. It should be noted that physicians tend
effective factor in drug prescription, regarding to work with the insurances as to attract more
the highest β in comparison with all four other patients. As a result, the vital role of the payer in
factors mentioned. health care system is not doubtable.
One of the distinctive characteristics of
the healthcare systems is the existence of Conclusion
intermediate parties, such as governments,
health maintenance organizations, or private This study integrated the different factors
insurers, which relates the price charged by the which are most significant determinants of
manufacturers and the quantity demanded by the decision making of the Iranian physicians, such
patients (23). The presence of insurance assures as drug characteristics, environmental factors,
the physicians to promote the choice of a more pharmaceutical company strategies, insurances

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Sharifnia S H et al. / IJPR (2018), 17 (3): 1105-1115

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