Integration of the Integrated Emergency Surgical Officers (IESO) initiative within the health system: Perspectives of non-physician surgeons in Ethiopia’s Tigray region

Background: Task-shifting and task-sharing are strategies for redistributing or collaboratively delivering clinical tasks within health workforce teams to address shortages and expand access. In Ethiopia, Integrated Emergency Surgical Officers (IESOs) were introduced to provide emergency obstetric and essential surgical care in underserved areas. In Tigray, conflict-related damage, displacement, workforce attrition, and disruption of referral and training systems intensified pre-existing surgical workforce shortages. Evidence on how IESOs have been integrated, supported, and retained in this fragile health-system context remains limited. This study assessed the status and experiences of IESOs in Tigray and identified strategies for strengthening their integration and retention. Methods: We conducted a concurrent mixed-methods study in November 2024. Of the 84 IESOs practising in Tigray, 59 attended the region-wide safe-cesarean-delivery training and all 59 completed the survey, giving a 100% response rate among invtied participants and representing 70.2% of practising IESOs in the region. Two focus group discussions with nine participants each and five in-depth interviews were conducted. Quantitative data were analyzed descriptively using R version 4.2.2, and qualitative data were analyzed thematically. Findings were integrated through triangulation and a joint display. Results: Participants worked across general hospitals, primary hospitals, and health centers. Most strongly agreed that IESOs contributed to reducing maternal mortality, 54(91.5%) and perinatal or neonatal mortality 48 (88.1%). The proportions who were very likely to remain in the profession declined from 31 (52.5%) at three years to 24 (40.7%) at five years and 7 (11.9%) at ten years, demonstrating a pronounced projected retention cliff. Resource shortages, limited managerial recognition, inter-professional conflict, and absent career-progression pathways were the dominant challenges, whereas community acceptance and the opportunity to initiate lifesaving services in remote settings were major sources of motivation. Conclusion: IESOs extend emergency obstetric and surgical services to underserved communities in Tigray, but their long-term retention is precarious. A sustainable program requires a nationally and regionally defined scope of practice, an appropriate salary and professional grading structure, funded continuing professional development, formal IESO specialization or advanced clinical career pathways, reliable surgical supplies and infrastructure, and structured collaborative governance with surgeons and obstetrician-gynecologists.