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4 Budget and Finances T he Committee assessed the Strategic Plan budgets, recognizing their im- portance in planning, monitoring, and assessment. Review of the budgets and financial information was limited because the Strategic Plans and Annual Reports were not sources of complete, up-to-date budget information and because interpreting the information proved difficult. AVAILABILITY OF BUDGET INFORMATION The availability of accurate, approved budget information was limited dur- ing the period of Committee review, from October 2004 through July 2005. Budget information should have been available from the Strategic Plan and the Annual Reports. However, the initial Strategic Plan budget (2002) had been approved but had not been developed with uniform definitions and methodology standards, and the draft of the unapproved 2004 Strategic Plan did not include budgets. Likewise, the first Annual Report (Fiscal Year [FY] 2001) detailing implementation of the Strategic Plan included a budget developed without uni- form methodology, as did the unapproved Annual Report for FY 2002. The unapproved Annual Report for FY 2003 used the newly developed methodology. INTERPRETATION OF BUDGET INFORMATION: DEFINITIONS AND METHODS The interpretation of budget information for National Institutes of Health (NIH) minority health and health disparities research for periods before FY 2003 60

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BUDGET AND FINANCES 61 is difficult because the definitions and methodology for coding across the NIH were not uniform. Before the initiation of the health disparities research program and the Strategic Plan, NIH Institutes and Centers (ICs) were already conducting extensive research related to minority health and health disparities. Most of this research involved the study of diseases, conditions, and circumstances that were important to the general population and that constituted major factors contribut- ing to disparate health statuses affecting minorities and other groups due to greater prevalence, increased severity, and worse outcomes. However, there were no standardized accounting methods for budget allocations to what was consid- ered to be minority health and health disparities research. Comparisons and trend assessments were less certain. Hence, the trans-NIH organization of the health disparities research initiative and the Strategic Plan emphasized the need for a uniform methodology and budget definitions. The NIH Research Definitions and Application Methodology (Boxes 4-1, 4-2, and Appendix H), the origins of which were described in Chapter 3, provided guidelines for reporting the two components of minority health and health dis- parities research: the Minority Health Report and the Health Disparities Report. The Health Disparities Report combines information from the Minority Health Report with data on activities addressing two additional health disparity popula- tions: low socioeconomic status and rural populations. Section 485(d)(1) of the enabling minority health and health disparities legislation defines a health dispar- ity population as one for which "if, as determined by the Director of the Center [NCMHD] after consultation with the Director of the Agency for Healthcare Research and Quality, there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population." The definitions of applicable research activities for basic research, infra- structure, and outreach projects include only projects targeted at minority health and health disparity issues. For clinical research, both targeted and nontargeted projects qualify, with nontargeted projects defined as those with rates of minority participants to total participants of 25 percent or greater. For low socioeconomic and rural groups, activity is reported based on emphasis levels assigned by the NIH's Computer Retrieval of Information on Scientific Projects (CRISP). Although adopted halfway through the 4th year of the 5-year program, the New Definitions and Methodology are useful standards created by a collective NIH effort. The new standards, applied in early 2004 and retroactively applied to FY 2003 NIH expenditures, promise to provide more reliable and useful data. INCREMENTAL FUNDING FOR THE NIH MINORITY HEALTH AND HEALTH DISPARITIES RESEARCH PROGRAM It is reasonable to expect that the health disparities research and Strategic Plan initiative would bring about additional NIH programs and other financial

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62 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH BOX 4-1 Minority Health Report Minorities are defined by statute as American Indians/Alaskan Natives (includ- ing Eskimos and Aleuts), Asian Americans, Native Hawaiians and other Pacific Is- landers, blacks, and Hispanics (i.e., individuals whose origin is Mexican, Puerto Rican, Cuban, Central or South American, or any other Spanish-speaking country). Targeted research (report at 100 percent) includes: basic research on a disease, condition, or biological process that affects exclusively or almost exclusively one or more minority populations; basic research on a behavior that is found exclusively or almost exclu- sively in one or more minority populations; basic research on whether and/or how the mechanisms of disease or basic biological processes differ in minority populations, or how behaviors differ in minority populations; clinical research conducted exclusively or almost exclusively in one or more minority populations; clinical research investigating whether and/or how the manifestations, con- sequences, or responses to treatment of diseases or other conditions differ in minority populations; and clinical research investigating how behaviors differ in minority populations. Nontargeted research (report at the percent minority participation, as long as it exceeds the threshold of 25 percent) includes: clinical research focused on prevention, diagnosis, or treatment of diseases or other conditions that affect minority populations. Targeted infrastructure (report at 100 percent) includes: solicited programs that are focused exclusively on developing the research capabilities of historically black colleges and universities and minority med- ical schools and solicited programs designed to enhance the research resources specifically available to underrepresented minorities at other institutions educating or training high numbers of one or more minority populations that are under- represented in biomedical or behavioral research. Targeted research training and career development (report at 100 percent) includes: programs that focus exclusively on supporting research training or career development of underrepresented minorities. Nontargeted research training and career development (report only dollars re- ceived by underrepresented minority individuals) includes: activities that support research training or career development of under- represented minority investigators, but that are not focused exclusively on these population groups. Targeted outreach (report at 100 percent) includes: programs that focus exclusively on providing health-related information to minority populations and programs that focus exclusively on providing information to health care providers about preventing, diagnosing, or treating diseases or other condi- tions in minority populations. SOURCE: NIH Committee on Minority Health and Health Disparities Research Definitions and Application Methodology (Appendix H).

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BUDGET AND FINANCES 63 BOX 4-2 Health Disparities Report Health disparities populations are minority populations, low socioeconomic status (low-SES) populations, and rural populations. Minority health issues are considered to be a subset of health disparities issues. The Health Disparities Report includes all activities in the Minority Health Report plus activities related to low-SES and rural populations. An activity that addresses minority health as well as low SES or rural health is included in the Health Disparities Report based on either its percent relevance to minority health or its percent relevance to low SES and rural health--whichever is higher. Targeted research (report at 100 percent) includes: basic research on a disease, condition, or biological process that affects exclusively or almost exclusively low-SES or rural populations; basic research on a behavior that is found exclusively or almost exclu- sively in low-SES or rural populations; basic research on whether and/or how the mechanisms of disease or basic biological processes differ in low-SES or rural populations, or how behav- iors differ in minority populations; clinical research on whether and/or how the manifestations, consequences, or responses to treatment of diseases or other conditions differ in low-SES or rural populations; and clinical research conducted exclusively or almost exclusively in low-SES or rural populations. Nontargeted research (report at 50/25 percent if coded in the NIH CRISP as sec- ondary/tertiary for low SES or rural health, or at the minority participation percent, if higher) includes: clinical research related to the manifestations, consequences, or responses to treatment of diseases or other conditions in low-SES or rural populations and clinical research conducted in populations that include low-SES or rural populations. Infrastructure is equal to the minority health figure for this category (due to difficul- ties in identifying institutions that educate large numbers of people from low-SES or rural populations). Research training and career development is equal to the minority health figure for this category (due to difficulties in identifying trainees of low-SES or rural back- grounds and institutions that educate large numbers of people from low-SES or rural populations). Targeted outreach (report at 100 percent) includes: programs that focus exclusively on providing health-related information to low-SES or rural populations and programs that focus exclusively on providing information to health care providers about preventing, diagnosing, or treating diseases or other condi- tions in low-SES or rural populations. SOURCE: NIH Committee on Minority Health and Health Disparities Research Definitions and Application Methodology (Appendix H).

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64 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH needs beyond those existing prior to 2000. Without incremental funding to NIH, progress in implementing the program could have been impeded by priority decisions with respect to other commitments. The reality that additional funding would be needed for funding for the NIH health disparities initiative was addressed in Section 485E(l) of P.L. 106-525: "For the purpose of carrying out this subpart, there are authorized to be appropri- ated $100,000,000 for fiscal year 2001, and such sums as may be necessary for each of the fiscal years 2002 through 2005. Such authorization of appropriations is in addition to other authorizations of appropriations that are available for the conduct and support of minority health disparities research or other health dis- parities research by the agencies of the National Institutes of Health." The authorized additional funds were not appropriated to NIH. It appears that the NIH director added $74.5 million of NIH funds to the health disparities initiative in FY 2001, of which $20 million was allocated to the National Center on Minority Health and Health Disparities and $54 million was distributed among the ICs, presumably increasing their base budgets. No such additional funding was appropriated in subsequent years. Thus, incremental funding to the NIH as specified by the legislation was not provided. NIH BUDGET ALLOCATIONS FOR HEALTH DISPARITIES The Committee attempted to compare appropriated funds and expenditures on minority health and health disparities activities within the ICs from FY 1998 to FY 2004 using published data and data provided by the Budget Office of the NIH Director, recognizing, as noted above, that except for 2003 and 2004, the data were not standardized in accordance with the new definitions and methodol- ogy. For all years, health disparities expenditures, as reported, include those for minority health, although they are discussed separately here. In 2000, at the onset of the health disparities research program, two of the 25 participating ICs (National Institute of Child Health and Human Development [NICHD] and National Institute of Nursing Research [NINR]) and the Office of the Director reported spending more than 20 percent of their budgets on minority health activities, and almost half of ICs reported spending more than 5 percent (Tables 4-1 and 4-2). Overall, NIH used approximately 8 percent of its budget for minority health programs in FY 2000. In FY 2002, total NIH funding for health disparities increased by 16.9 percent over FY 2001 levels, from $23.7 billion to $27.7 billion; in FY 2003, it increased another 14.2 percent to $31.6 billion, according to the original accounting methodology for estimating spending (fig- ures for health disparities were not reported in 2000; Table 4-3).1 With the appli- cation of the new definitions and methodology, the adjusted 2003 funding for health disparities was reported to be $24.3 billion, $734.5 million less than origi- 1Amounts are not adjusted for inflation.

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BUDGET AND FINANCES 65 TABLE 4-1 Percentage of Total Appropriation Used for Minority Health Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 19992004 Participating 1998 1999a 2000a 2001a 2002a 2003a 2003b 2004b ICs % % % % % % % % NCI 2.97 2.62 2.75 2.76 2.91 2.87 3.06 4.61 NHLBI 8.73 9.25 10.23 9.43 9.40 9.54 9.76 10.07 NIDCR 7.95 6.75 5.12 5.95 5.59 6.48 8.81 10.05 NIDDK 8.98 8.64 9.45 9.00 8.53 11.06 11.06 10.17 NINDS 1.95 2.40 2.42 2.86 3.71 3.93 5.16 4.81 NIAID 0.60 14.52 14.08 13.87 14.14 7.84 7.79 8.05 NIGMS 6.69 7.39 8.32 8.47 8.21 8.24 8.24 8.53 NICHD 14.05 22.69 23.73 24.65 24.94 25.22 13.33 13.38 NEI 3.24 3.57 4.06 4.05 3.99 3.63 2.47 2.60 NIEHS 3.89 3.44 4.58 3.99 3.62 1.02 2.18 2.66 NIA 9.18 8.80 8.67 8.38 8.51 8.72 10.58 11.41 NIAMS 11.11 10.03 9.61 9.80 10.96 10.94 7.11 6.15 NIDCD 1.94 1.81 1.16 1.07 1.71 2.29 5.02 5.68 NIMH 2.26 1.95 2.20 2.02 2.14 13.14 13.14 13.33 NIDA 8.36 8.00 8.08 8.29 8.43 8.98 10.14 9.61 NIAAA 14.70 16.22 9.23 9.81 9.36 0.84 8.74 8.31 NINR 18.05 20.77 22.27 21.44 23.34 21.07 21.06 22.35 NHGRI 1.29 1.65 1.33 2.03 2.51 2.61 2.29 3.61 NIBIB -- -- -- -- 0.28 0.36 3.82 3.17 NCRR 7.33 6.05 5.77 4.89 4.81 5.45 5.18 5.06 NCCAM -- -- 5.67 14.04 7.07 9.94 9.94 10.81 NCMHD -- -- -- 96.17 93.45 83.36 83.36 83.37 FIC 0.00 2.84 2.73 2.21 1.78 0.74 0.74 2.08 NLM 0.92 1.30 1.11 1.55 3.17 1.07 1.07 1.26 OD 25.62 28.10 33.74 0.00 2.52 3.08 3.15 1.88 NIH 6.02 7.79 7.96 8.00 8.11 7.89 7.72 8.21 NOTE: Acronyms: see Appendix I. -- Not applicable. aCalculation is based on the prior methodology for defining minority health. bCalculation is based on the new definition of minority health. SOURCE: NIH, 2005. nally estimated for 2003. In 2004, the annual increment represented a 6.6 percent increase, which was lower than before the application of the new methodology but still greater than the total NIH budget increase of 3.0 percent. The change in methodology revealed that NIH was spending approximately 3 percent less of its total budget on health disparities activities than originally reported in FY 2003. The percentage of the total NIH budget allocated to health disparities research was reported to be 11 percent in 1999 and 12 percent each year from 2001 to 2003 (old methodology; Figure 4-1 and Table 4-4). After application of the new methodology to the 2003 data, NIH allocated 9 percent in

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66 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH TABLE 4-2 Annual Expenditures on Minority Health Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 19982004 (Dollars in Millions) Participating ICs 1998a 1999a 2000a 2001a 2002a 2003a 2003b 2004b NCI $75.6 $76.6 $91.3 $103.5 $121.9 $131.7 $140.4 $218.3 NHLBI 133.7 165.9 207.7 216.7 241.7 266.5 272.7 289.7 NIDCR 16.7 15.8 13.8 18.2 19.1 24.1 32.7 38.5 NIDDK 80.9 88.2 110.5 126.0 133.2 190.5 190.5 185.2 NINDS 15.3 21.7 24.9 33.7 49.2 57.2 75.1 72.2 NIAID 8.1 227.8 250.3 283.1 331.3 282.9 281.0 334.3 NIGMS 71.3 88.5 112.7 130.1 141.7 152.2 152.2 162.5 NICHD 94.8 170.3 203.6 240.6 277.2 304.1 160.8 166.3 NEI 11.5 14.1 18.3 20.7 23.2 23.0 15.6 17.0 NIEHS 12.8 12.9 20.3 22.5 23.4 7.1 15.2 18.9 NIA 47.7 52.4 59.5 65.8 75.9 86.6 105.1 116.9 NIAMS 30.5 30.9 33.6 38.9 49.1 53.2 34.6 30.8 NIDCD 3.9 4.2 3.1 3.2 5.8 8.5 18.6 21.7 NIMH 16.9 16.8 21.4 22.3 26.7 176.3 176.3 184.2 NIDA 44.1 48.2 55.4 64.7 74.7 86.3 97.5 95.2 NIAAA 33.4 42.1 27.0 33.4 35.9 3.5 36.4 35.6 NINR 11.5 14.5 19.9 22.4 28.1 27.5 27.5 30.1 NHGRI 2.8 4.4 4.5 7.8 10.8 12.1 10.6 17.3 NIBIB -- -- -- -- 0.3 1.0 10.6 9.1 NCRR 33.3 33.6 39.0 40.0 48.7 62.1 59.0 59.7 NCCAM -- -- 3.9 12.5 7.4 11.3 11.3 12.6 NCMHD -- -- -- 125.1 147.2 154.8 154.8 159.6 FIC 0.0 1.0 1.2 1.1 1.0 0.5 0.5 1.4 NLM 1.5 2.4 2.4 3.8 8.8 3.2 3.2 4.0 OD 75.9 86.1 95.2 0.0 5.9 8.2 8.4 6.1 NIH 822.2 1,218.2 1,419.3 1,636.1 1,888.4 2,134.3 2,090.5 2,287.4 NOTE: Acronyms: see Appendix I. -- Not applicable. aCalculation is based on the prior methodology for defining minority health. bCalculation is based on the new definition of minority health. SOURCE: NIH, 2005. both 2003 and 2004. For minority health research, NIH spent approximately 8 percent of its total funding annually from 1999 through 2004 (Table 4-1). Even after application of the new methodology, the percentage did not change much, as seen in Figure 4-1. The new methodology seemed mostly to affect the health disparities component. An NIH view of the adjusted allocations report (Zerhouni, 2004) noted large changes in three ICs: the National Institute of Allergy and Infectious Diseases (NIAID), with a change of $451 million in the health disparities portion of the 2003 budget; the National Cancer Institute (NCI), with a change of $157 million;

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BUDGET AND FINANCES 67 TABLE 4-3 Annual Expenditures on Health Disparities Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1999, 20012004a (Dollars in Millions) Participating ICs 1999b 2001b 2002b 2003b 2003c 2004c NCI $197.0 $350.3 $383.1 $414.0 $256.6 $264.8 NHLBI 177.1 218.2 255.1 279.0 276.9 295.3 NIDCR 13.7 19.0 24.4 27.1 36.9 42.3 NIDDK 88.2 126.0 133.2 237.9 196.4 197.7 NINDS 89.7 33.7 49.2 57.2 77.9 73.8 NIAID 460.8 579.5 663.3 734.7 282.9 338.1 NIGMS 89.6 149.8 150.9 162.0 174.6 202.4 NICHD 173.1 242.9 280.7 307.0 180.1 184.5 NEI 24.1 36.3 39.8 40.7 16.6 18.4 NIEHS 22.4 30.4 32.5 33.7 29.1 31.2 NIA 58.4 73.3 84.6 91.5 142.3 158.8 NIAMS 31.6 38.8 48.7 54.3 36.1 32.3 NIDCD 4.2 4.5 5.8 8.5 19.9 22.8 NIMH 124.7 160.0 182.9 202.9 202.9 213.2 NIDA 89.7 26.9 95.8 120.4 119.0 127.3 NIAAA 30.1 33.4 35.9 34.6 39.8 39.3 NINR 26.2 28.9 29.4 32.2 34.8 36.9 NHGRI 6.1 10.2 10.9 13.7 12.2 19.1 NIBIB -- -- 0.3 1.7 12.3 11.5 NCRR 51.6 64.9 89.1 100.5 74.5 66.6 NCCAM -- 12.5 7.8 11.5 11.5 12.8 NCMHD -- 125.1 154.2 181.7 181.7 186.4 FIC 1.0 1.1 1.0 2.3 0.6 1.4 NLM 2.8 3.0 6.6 6.1 3.6 5.6 OD 4.7 2.8 6.4 9.2 10.9 6.2 NIH 1,766.8 2,371.5 2,771.6 3,164.4 2,429.9 2,588.6 NOTE: Fiscal Year 2000 funding information was not collected. Acronyms: see Appendix I. -- Not applicable. aIncludes minority health expenditures reported in Table 4-2. bCalculation is based on the prior methodology for defining minority health. cCalculation is based on the new definition of minority health. SOURCE: NIH, 2005. and NICHD, with a $127 million change. All these changes were ascribed to heavy clinical trial activity supported by those ICs and the impact of the new methodology on accounting for clinical trials. The revised methodology had varying effects on the ICs' reported alloca- tions. The proportions of budgets allocated to health disparities research were adjusted downward for NCI, the National Eye Institute, NIAID, the National Institute of Diabetes and Digestive and Kidney Diseases, and NICHD. The larg- est change was for NICHD, which demonstrated a 40 percent drop in the previ- ously reported allocation to health disparities research and almost a 50 percent

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68 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH 14 11.59 11.90 11.69 12 11.30 10 9.29 8.98 8.21 7.79 7.96 8.00 8.11 7.89 7.72 8 Appropriations Total 6 of 4 Percent 2 0 FY1999* FY 2000* FY 2001* FY 2002* FY 2003* FY 2003** FY 2004** Health Disparities Minority Health FIGURE 4-1 Percentage of total NIH budget funding minority health and health dispari- ties research activities between 1999 and 2004. SOURCE: NIH Office of Budget, 2005. NOTE: Health disparities includes minority health expenditures plus low SES and rural health research expenditures. * Estimates derived from old accounting methodology. ** Estimates derived from new accounting methodology. drop for minority health research. Increases were seen for the National Institute on Aging, the National Institute on Deafness and Other Communication Disor- ders, and the National Institute of Dental and Craniofacial Research. Even after the application of the new methods, NICHD channeled comparatively large allo- cations to health disparities research (15 percent). Likewise, NINR allocated 25 percent of its budget to such research. The NIH budget approximately doubled from $13.6 billion in 1998 to $27.1 billion in 2003 (Table 4-5).2 Funding for projects related to minority health increased during that period from $0.8 billion to $2.1 billion (Table 4-2). Even when measured against the adjusted 2003 minority health budget figures, spend- ing on minority health research kept pace with the doubling of the NIH budget that occurred between 1998 and 2003. 2Budgets are compared in current dollars.

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BUDGET AND FINANCES 69 TABLE 4-4 Percentage of Total Appropriation Used for Health Disparities Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1999, 20012004a Participating 1999b 2001b 2002b 2003b 2003c 2004c ICs % % % % % % NCI 6.73 9.33 9.15 9.01 5.59 5.59 NHLBI 9.88 9.49 9.91 9.99 9.91 10.26 NIDCR 5.85 6.20 7.13 7.29 9.92 11.04 NIDDK 8.64 9.00 8.53 13.81 11.40 10.85 NINDS 9.94 2.86 3.71 3.93 5.35 4.92 NIAID 29.37 28.38 28.32 20.37 7.84 8.14 NIGMS 7.49 9.76 8.75 8.77 9.45 10.63 NICHD 23.07 24.89 25.25 25.46 14.93 14.85 NEI 6.09 7.11 6.86 6.42 2.62 2.82 NIEHS 5.96 5.38 5.04 4.83 4.16 4.40 NIA 9.79 9.33 9.48 9.21 14.32 15.49 NIAMS 10.27 9.80 10.87 11.17 7.42 6.45 NIDCD 1.81 1.49 1.71 2.29 5.38 5.97 NIMH 14.49 14.47 14.67 15.13 15.13 15.43 NIDA 14.88 3.44 10.81 12.51 12.37 12.85 NIAAA 11.59 9.81 9.36 8.33 9.57 9.17 NINR 37.57 27.70 24.39 24.68 26.65 27.37 NHGRI 2.31 2.67 2.55 2.94 2.62 3.99 NIBIB -- -- 0.28 0.61 4.44 4.01 NCRR 9.31 7.94 8.81 8.82 6.54 5.65 NCCAM -- 14.04 7.49 10.12 10.12 10.96 NCMHD -- 96.17 97.85 97.81 97.81 97.36 FIC 2.82 2.21 1.78 3.58 0.94 2.08 NLM 1.55 1.22 2.41 2.04 1.19 1.77 OD 1.54 1.32 2.70 3.47 4.10 1.88 NIH 11.30 11.59 11.90 11.69 8.98 9.29 NOTE: Fiscal Year 2000 funding information was not collected. Acronyms: see Appendix I. -- Not applicable. aIncludes minority health expenditures reported in Table 4-1. bCalculation is based on the prior definition of health disparities research. cCalculation is based on the new definition of health disparities research. SOURCE: NIH, 2005. During the period of budget doubling, most ICs witnessed a budget increase of at least 75 percent (Table 4-5). The available information suggests that for most ICs, the portion of their budgets attributed to minority health and health disparities research increased proportionally to, or at a greater rate, than their budget change--though for some, reported increments were far less. Currently, the proportion of expenditures on health disparities varies by IC, with the mean being about 9 percent (Table 4-4). Over the short period that the Strategic Plan has been in effect, there is no indication that this proportion has increased.

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70 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH TABLE 4-5 Annual Appropriations of the NIH Institutes and Centers (ICs), Fiscal Years 19982004 (Dollars in Millions) Participating ICs 1998 1999 2000 2001 2002 2003 2004 NCI $2,547 $2,925 $3,315 $3,754 $4,181 $4,592 $4,739 NHLBI 1,531 1,793 2,029 2,299 2,573 2,794 2,879 NIDCR 209 234 269 306 343 372 383 NIDDK 901 1,021 1,168 1,400 1,562 1,723 1,822 NINDS 781 903 1,029 1,176 1,327 1,456 1,501 NIAID 1,352 1,569 1,778 2,042 2,342 3,607 4,155 NIGMS 1,066 1,197 1,354 1,535 1,725 1,847 1,905 NICHD 675 750 858 976 1,112 1,206 1,242 NEI 356 396 450 510 581 633 653 NIEHS 330 375 442 565 645 698 711 NIA 519 596 686 786 892 994 1,025 NIAMS 275 308 350 396 448 486 501 NIDCD 201 230 264 300 342 370 382 NIMH 750 861 973 1,106 1,247 1,341 1,382 NIDA 527 603 686 781 887 962 991 NIAAA 227 260 292 340 384 416 429 NINR 64 70 90 104 120 131 135 NHGRI 218 265 336 382 429 465 479 NIBIB -- -- -- -- 112 278 287 NCRR 454 554 677 817 1,011 1,139 1,179 NCCAM -- -- 68 89 104 113 117 NCMHD -- -- -- 130 158 186 191 FIC 28 35 43 50 57 63 65 NLM 161 181 214 246 276 300 317 OD 296 306 282 212 235 266 328 NIH 13,648 15,629 17,821 20,458 23,296 27,067 27,888 NOTE: Acronyms: see Appendix I. -- Not applicable. SOURCE: NIH, 2005. The amount of funds that NIH should allocate to minority health and health disparities research remains an open question. It could be said that with the proper assessment of needs, careful planning, and appropriate priority setting, the budget will reflect the importance of addressing health disparities and the com- mitment expressed by Congress and NIH to face this challenge. However, little evidence to date suggests that such analyses, projections, and decisions have been coordinated across the NIH-wide program. The proportions reported likely represent budget priorities made within ICs, which were not available for review for the overall health disparities research program and the Strategic Plan. NIH ICs have budget commitments and priorities dependent on budget presentations to, and funding authorizations by, Congress. The NIH's overall agency priority for health disparities research, third among the agency's top five priorities (Morton, 2005; Zerhouni, 2004), should be a factor in

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BUDGET AND FINANCES 71 the ICs' priority processes. The ICs' processes for establishing such priorities should be of concern to those responsible for the overall health disparities re- search and Strategic Plan program, as well as to other reviewers. Furthermore, information from such considerations could be the bases of arguments for addi- tional categorical funds to NIH or to the respective ICs. Other concerns arise from the use of budget and financing information for proper planning, monitoring, and decisions about the Strategic Plan. For ex- ample, the general public, Congress, other government agencies, and organiza- tions with a special interest in the Strategic Plan should know what resources are being expended in specific categories related to the health disparities research efforts and the Strategic Plan. It would be helpful to have the budget information categorized by funding for each goal area--along with the funds allocated for each objective under each goal--for future monitoring of the program and the Strategic Plan as a whole and individually for each IC and Office involved. In addition, trans-NIH funding information could be available for specific entities and problems (e.g., minority health/health disparities-related programs in obesity, diabetes, AIDS, infant health) as well as for the support allocated to research faculty development, educational institutions, minority-serving institu- tions, community-based research, and specific outreach endeavors, such as com- munication with providers and communities. Findings: Incremental funding was not provided to NIH for the minority health and health disparities research program. As of July 2005, during the 5th year of the program period, no complete, standardized, approved budget information was avail- able from the Strategic Plan or the Annual Reports. The absence of such information calls into question the validity and efficacy of the Strategic Plan and Annual Reports as tools for planning and coordination. For more accurate evaluation, detailed information on specific cat- egories and aspects of the minority health and health disparities research program and the Strategic Plan would be helpful. Recommendation 8: Within NIH, a clear and timely budget process should be linked to the Strategic Plan, and it should be updated in a timely manner. Annual budgets should include information for NIH as a whole, and for each involved IC and office, and should detail allocations for the Strategic Plan goal areas and each objective. Trans-NIH budget information on efforts made in the major categories of research, re- search capacity, and communication also should be made available.