title: Modeling solutions to Tanzania's physician workforce challenge.
abstract: BACKGROUND
  There is a great need for physicians in Tanzania. In 2012, there were approximately 0.31 physicians per 10,000 individuals nationwide, with a lower ratio in the rural areas, where the majority of the population resides. In response, universities across Tanzania have greatly increased the enrollment of medical students. Yet evidence suggests high attrition of medical graduates to other professions and emigration from rural areas where they are most needed.
  
  
  OBJECTIVE
  To estimate the future number of physicians practicing in Tanzania and the potential impact of interventions to improve retention, we built a model that tracks medical students from enrollment through clinical practice, from 1990 to 2025.
  
  
  METHODS
  We designed a Markov process with 92 potential states capturing the movement of 25,000 medical students and physicians from medical training through employment. Work possibilities included clinical practice (divided into rural or urban, public or private), non-clinical work, and emigration. We populated and calibrated the model using a national 2005/2006 physician mapping survey, as well as graduation records, graduate tracking surveys, and other available data.
  
  
  RESULTS
  The model projects massive losses to clinical practice between 2016 and 2025, especially in rural areas. Approximately 56% of all medical school students enrolled between 2011 and 2020 will not be practicing medicine in Tanzania in 2025. Even with these losses, the model forecasts an increase in the physician-to-population ratio to 1.4 per 10,000 by 2025. Increasing the absorption of recent graduates into the public sector and/or developing a rural training track would ameliorate physician attrition in the most underserved areas.
  
  
  CONCLUSIONS
  Tanzania is making significant investments in the training of physicians. Without linking these doctors to employment and ensuring their retention, the majority of this investment in medical education will be jeopardized.
authors.affiliation: School of Medicine, University of California San Francisco, San Francisco, CA, USA; alexgoodell@gmail.com.
authors.forename: Alex J
authors.initials: AJ
authors.lastname: Goodell
authors.affiliation: Philip R Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA.
authors.forename: James G
authors.initials: JG
authors.lastname: Kahn
authors.affiliation: Independent consultant, PRAXIS, Tanzania.
authors.forename: Sidney S
authors.initials: SS
authors.lastname: Ndeki
authors.affiliation: School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
authors.forename: Eliangiringa
authors.initials: E
authors.lastname: Kaale
authors.affiliation: School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
authors.forename: Ephata E
authors.initials: EE
authors.lastname: Kaaya
authors.affiliation: Global Health Sciences, University of California, San Francisco, CA, USA.
authors.forename: Sarah B J
authors.initials: SB
authors.lastname: Macfarlane
keywords: Tanzania; doctor shortage; modeling; workforce