Our testimonials give a voice to experts working on the ground, sharing first-hand experiences with the Global-PPS tool. In this article, we speak with Dr. Ralalicia Limato, a medical doctor, health systems researcher, and a key contributor to the drive-AMS project in Indonesia. She reflects on the challenge of antimicrobial resistance (AMR) in the country and explains how the Global-PPS has evolved from a research tool into a cornerstone of Indonesia’s national surveillance system for antimicrobial use and healthcare-associated infections. Dr. Limato highlights the value of Global-PPS in capturing both the quantity and quality of antibiotic prescribing, its role in guiding targeted stewardship interventions, and the lessons learned from implementing the tool across diverse hospital settings in Indonesia.

Could you tell a bit about yourself and your professional background?

Ralalicia Limato: My name is Ralalicia Limato. I’m a medical doctor and I have been working as a health system researcher and quality improvement consultant for around 13 years. I have a master’s degree in public health and two years ago I finished my PhD in clinical medicine, so my background is really a mix of the two disciplines. I now work on several projects as a consultant, including the drive-AMS project in Indonesia where we work with the Global-PPS.

Why is tackling antimicrobial resistance so crucial? And how does it affect patients in Indonesia?

Ralalicia Limato: Before antimicrobials existed, people used to live only up to 30 or 40 years, many due to different infections, like tuberculosis. We now have the privilege to live longer because of antimicrobials, and of course also because of better infrastructure, dietary measures and support systems. But bacteria have developed resistance to these antimicrobials, and we might go back to the old era where we mortality rates increase because there is no cure for infections anymore. That’s why tackling antimicrobial resistance is so important.

Can you describe the process of Global-PPS being adopted as Indonesia’s national surveillance system for antimicrobial use and healthcare-associated infections?

Ralalicia Limato: I first learned about Global-PPS during my PhD, when my supervisor suggested using the tool to assess antimicrobial preference and usage. I believe this was also the first time Global-PPS was used in Indonesia. At the time, however, we didn’t submit data to the Global-PPS database, because we added a couple of variables that were important for the Indonesian health insurance system.

After we published the results, the Fleming Fund Country Grant (FFCG) Indonesia contacted us to share our experience with PPS data collection. We then provided training on how to collect PPS data, and later the FFCG conducted the PPS data collection and continued their broader AMR-related interventions in Indonesia. Later, when drive-AMS started working in Indonesia in collaboration with the Ministry of Health, representatives from FFCG Indonesia were invited to join the drive-AMS training which included the Global-PPS. They saw how useful and easy the tool is, the level of support it offers for data analysis, and the benefits of benchmarking in the reported data. Based on this experience, FFCG Indonesia advocated with the Ministry of Health to include Global-PPS in Indonesia’s AMR policy, which eventually led to Global-PPS being adopted as part of the national surveillance system.

How did participants perceive the Global-PPS? And how did this differ from the previously used data collection method in Indonesia, the DDD?

Ralalicia Limato: I found that people from hospitals, especially from the hospitals we are working with within drive-AMS, say that it’s easy to use. Of course, sometimes filling in the survey might be a bit confusing, but that’s usually not because of the Global-PPS tool itself. It’s more often because the prescriber didn’t write the diagnosis clearly, which makes it difficult to understand why an antibiotic was prescribed. Overall, I think it’s an easy tool and it doesn’t take a long time to train people to use it. People say they quickly adjust to the data collection rhythm and that it often only takes about five minutes per patient to complete. It can take a bit longer if a patient was prescribed with different antibiotics or if there are multiple culture results.

In Indonesia, our national AMR policy requires hospitals to assess the quantity of antibiotic use by using Defined Daily Dose (DDD) and the quality of prescribing practices using the Gyssens method. For DDD, hospitals usually extract data from pharmacy systems. That can be relatively straightforward, but it depends a lot on the hospital’s IT system. In some hospitals, patient data and pharmacy data are stored in different systems, which means staff have to log into multiple platforms to collect the information. Gyssens method is an audit-type assessment that requires  experts in infectious disease and clinical microbiology to be present during the data collection.

The key difference between DDD and the Global-PPS is that DDD data quantify antibiotic use but do not provide insight into prescribing quality. In contrast, Global-PPS captures information on indication, diagnosis and whether antibiotic use is appropriate, either empirically or definitively based on culture and susceptibility results. As such, Global-PPS enables assessment of both quantity and quality of antibiotic prescribing.

Did you encounter any challenges during the implementation of the Global-PPS in hospitals?

Ralalicia Limato: For the method, tool, and training people to use it, I would say no. The challenges were more present at hospital level, mainly in terms of human resources to perform the data collection. The Ministry of health requires at least one round of data collection per year. Some hospitals depend on students or residents to perform the data collection, but they come and go, which isn’t very sustainable. That’s why we suggested training clinical pharmacists, because they stay in the hospital.

How would you describe drive-AMS Indonesia and the role of the Global-PPS in the project?

Ralalicia Limato: The concept of drive-AMS is to teach hospitals how to implement antimicrobial stewardship in a stepwise manner. What I often see is that hospitals quickly jump into interventions without really understanding what the actual problem with antibiotic use is and do not explore the social, context-specific factors influencing the problem. For example, they may notice a high rate of prolonged surgical antibiotic prophylaxis but not explore the reasons why this is happening, such as prescribing habits passed down from senior doctors.

With drive-AMS, we ask hospitals to first collect data using Global-PPS. Then we work together with the hospital teams to analyze the data and identify ‘the low hanging fruit’ aspect that can be improved. After that, implementation and measurement follow, often using process indicators that the hospitals develop themselves.

Any other insights or feedback that you would like to share with the Global-PPS community?

Ralalicia Limato: I think social factors like disability, gender equity, and social inclusion are also important in antibiotic use and the AMR problem. At the moment, we only have sex and age to analyze antibiotic use. It would be good to start thinking about including more variables that capture more of the social and contextual background of patients. AMR doesn’t impact everyone equally, and having data on this could support more targeted and effective stewardship interventions.

Curious to hear more insights from the Global-PPS community? Keep an eye on our website throughout the year, as we will be sharing many more testimonials from experts around the world. We will also be taking a deeper dive into the Indonesian Global-PPS story in an upcoming follow-up interview with Dr. Amy Rahmadanti from the Indonesian Ministry of Health, where we will explore the national perspective on surveillance, policy, and antimicrobial stewardship in greater detail.