for research into basic biological and medical problems. While the harsh economic realities of the Great Depression imposed constraints, this legislation marked a new commitment to public funding of medical research and training. The National Cancer Act of 1937, which established the National Cancer Institute (NCI) within the Public Health Service (PHS), funded the first training programs targeting a specific area. This legislation supported training facilities and the award of fellowships to outstanding individuals for studies related to the causes and treatment of cancer. In 1938, 17 individuals received fellowships in cancer-related research fields such as biochemistry, physiology, and genetics.
NCI became part of NIH with the passage of the Public Health Services Act of 1944—the legislative basis for NIH’s wartime and postwar expansion of research and training programs and more generally for a major federal commitment to support biomedical research. This expansion was supported by legislative actions that converted existing divisions within NIH to institutes and centers and the establishment of new institutes or centers, each with field-specific training and research missions. In particular, the first of these laws—the National Heart Act of 1947—established the National Heart Institute and changed the name of the National Institute of Health to the National Institutes of Health.
Throughout the 1940s, 1950s, and 1960s there was substantial growth in the NIH budget, with annual increases averaging 40 percent from 1957 to 1963 (with dollar increases ranging from $98 million to $930 million). This funding raised the number of grants to academic institutions and enabled greater federal assistance in both the construction of research facilities and the establishment of fellowship and training programs for research personnel; this generous funding even allowed for limited investment to support research in foreign countries. The growth in research and training support slowed in the late 1960s, to about 6 percent annually, with a consequent decline in the number of research grants, both foreign and domestic, and a curtailment of facilities construction.
Support in the 1970s reflected public and congressional interest in specific diseases. Research areas such as cancer and pulmonary and vascular disorders were identified by legislation for increased funding, and the eleventh institute on the NIH campus, the National Institute on Aging (NIA), was established in 1974. The NIA also brought a new perspective to NIH in that it was authorized to support not only biological research but also social and behavioral research. While funding for research in targeted areas was welcomed at NIH, this also meant that research in less visible areas tended to decline. Institutes such as the National Institute for General Medical Sciences (NIGMS) and the National Institute of Allergy and Infectious Diseases saw annual average reductions of about 10 percent.
By the early 1970s, training support was authorized through the different institutes and centers by 11 separate pieces of legislation. However, in its FY 1974 budget recommendations, the administration proposed the phasing out of research training and fellowship programs over a five-year period by making no new awards and honoring only existing commitments. The reasons it cited for this proposal were as follows: the need for such programs and the manpower trained by them had never been adequately justified; people trained in these programs earned incomes later in life that made it reasonable to ask them to bear the cost of their training; large numbers of those trained did not enter biomedical research or continue their training; alternative federal programs of support for this training were available; and the programs were not equitable because support was not available equally to all students.3
The administration’s proposal met with virtually universal opposition by members of the nation’s biomedical research community. As a result, the administration revised its position and proposed a new, but smaller, fellowship program at the postdoctoral level. This proposal also met with objections, and in 1974 Congress enacted the National Research Act (P.L. 93-348), which amended the Public Health Services Act by repealing existing research training and fellowship authorities and consolidating them into the National Research Service Award (NRSA) program. The legislation authorized support for individual and institutional training grants at the predoctoral and postdoctoral levels, with the stipulation that an individual could be supported for no more than 3 years. Moreover, to safeguard against some of the cited abuses of the former programs, it restricted training support on the basis of subject-area shortages and imposed service obligations and payback requirements.
In the years since the National Research Act was signed, the law governing the NRSA program has been modified several times in order to include new areas of research training and establish funding levels for selected disciplines. The first change came in 1976, when Congress extended the program to encompass research training in nursing.4 Then, in 1978, Congress expanded the NRSA program to cover training in health services research.5 In 1985 the program was enlarged once again to include training in primary care research.6
Specific funding targets for training in health services and primary care research were established with the Health Research Extension Act of 1985, when Congress required that 0.5 percent of NRSA funds be allocated to each of the two fields.7 The same law directed that funds for training in health services research be administered by the Agency for Health Care Policy and Research (AHCPR) and its successor, the Agency for Healthcare Research and Quality (AHRQ). Research training in primary care originally came