A qualitative study of barriers to antimicrobial stewardship in Indonesian hospitals: governance, competing interests, cost, and structural vulnerability

Background: Antimicrobial resistance (AMR) is one of the leading global public health threats of the 21st Century. Antimicrobial stewardship (AMS) programmes have been shown to improve antibiotic use and clinical outcomes in high-income settings, but context-specific evidence is lacking on the value and effectiveness of current AMS programmes in low-resource settings. This study sought to explore context-specific underlying barriers to AMS implementation in Indonesian hospitals with a focus on governance practices and structural vulnerabilities. Methods: We conducted semi-structured interviews with physicians, surgeons, clinical microbiologists, pharmacists, AMS team leaders, hospital managers, medical students, and national AMR stakeholders, and performed a thematic analysis. Results: Based on 51 interviews conducted between January and October 2020, four main barriers to AMS implementation were evident in the participants' experiences: (1) Ineffective resourcing and institutional buy-in regarding mandatory AMS under hospital accreditation; (2) Entangled priorities to generate profits and interprofessional relationships between doctors and hospital managers or AMS leaders; (3) Cost-prohibitive bacterial culture testing and thresholds of national health insurance coverage; (4) Unreliable infrastructures, including microbiology laboratory and surgical facilities, ensuring high antibiotic usage to cover structural vulnerabilities. Conclusions: Limited progress will be made with implementing AMS in Indonesian hospitals, and in settings with similar structural features, without addressing concerns around governance, competing interests, cost and structural vulnerabilities.