Executive Summary

The Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) was created in 1973 as the result of many factors, including the notion of an inherent relatedness among the problems of alcoholism, drug abuse, and mental illness (the ADM disorders), and the presumption that research into mental illness would provide insights into the etiology of alcoholism and drug abuse. ADAMHA's status as a categorical agency also reflects the presumption that community-based treatment services could best be provided through affiliation and coordination among federal activities related to ADM disorders. Since the agency 's inception, the expectations for it have included sharper research focus on the interrelated ADM disorders, rapid translation of research into service delivery, and increased efficiency and effectiveness of treatment and prevention services through program integration. Over the past 25 years, a number of attempts have been made to reform the organizational structure of the Public Health Service (PHS). The expressed goals of reorganizations include increasing efficiency and economy, promoting more effective planning and coordination, and reducing fragmentation or overlap. The reorganizations have also had political goals.

A number of underlying questions were raised during the last major reorganization of the PHS in 1973 and again in 1988, when a study was conducted to develop organizational options for ADAMHA:

  • How, if at all, does organizational structure influence research, prevention, and services development or demonstration programs within the PHS?

  • Does the administration of these different types of programs in a single agency (i.e., ADAMHA) produce results that are different from those obtained in organizational structures in which these



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Research and Service Programs in the PHS: Challenges in Organization Executive Summary The Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) was created in 1973 as the result of many factors, including the notion of an inherent relatedness among the problems of alcoholism, drug abuse, and mental illness (the ADM disorders), and the presumption that research into mental illness would provide insights into the etiology of alcoholism and drug abuse. ADAMHA's status as a categorical agency also reflects the presumption that community-based treatment services could best be provided through affiliation and coordination among federal activities related to ADM disorders. Since the agency 's inception, the expectations for it have included sharper research focus on the interrelated ADM disorders, rapid translation of research into service delivery, and increased efficiency and effectiveness of treatment and prevention services through program integration. Over the past 25 years, a number of attempts have been made to reform the organizational structure of the Public Health Service (PHS). The expressed goals of reorganizations include increasing efficiency and economy, promoting more effective planning and coordination, and reducing fragmentation or overlap. The reorganizations have also had political goals. A number of underlying questions were raised during the last major reorganization of the PHS in 1973 and again in 1988, when a study was conducted to develop organizational options for ADAMHA: How, if at all, does organizational structure influence research, prevention, and services development or demonstration programs within the PHS? Does the administration of these different types of programs in a single agency (i.e., ADAMHA) produce results that are different from those obtained in organizational structures in which these

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Research and Service Programs in the PHS: Challenges in Organization programs are separately administered, such as in the National Institutes of Health (NIH), the Centers for Disease Control (CDC), and the Health Resources and Services Administration (HRSA)? Are research results more easily transferred and applied to the structure and delivery of health care in an agency such as ADAMHA, which has statutory responsibility for research, prevention, and services development and demonstration programs? Under what organizational structure can the research and service missions of the PHS best be carried out? This study responds to a congressional requirement in the Anti-Drug Abuse Act of 1988 (P.L. 100-690) that the Secretary of Health and Human Services request the National Academy of Sciences to conduct a review of the research activities of NIH, ADAMHA, and related agencies. Specifically, the committee was asked for: an evaluation of the appropriateness of administering health service programs in conjunction with the administration of biomedical and behavioral research; and a determination of the extent of duplication among selected research programs of NIH and ADAMHA. To answer these questions, the committee was asked to develop and establish criteria and/or measures for determining the following: the effects of administering service programs in conjunction with research and research-related activities; the extent and effects of duplication, replication, and complementarity between the research activities of NIH and ADAMHA; the administrative, program, and policy relationships among service programs and research activities of ADAMHA and its institutes, and the extent to which patterns of communication and leadership activities are attributable to co-administration or to other factors; and the “appropriateness” of these effects, given both the statutory mission of the programs and the changing requirements of public policy, scientific opportunity, and economic conditions. The questions posed by Congress do not lend themselves to a completely objective approach; by nature they include subjective evaluations. Consequently, data and information gathered for this study were supplemented by the expertise of diverse committee and task force members. Analyses conducted for this study include three

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Research and Service Programs in the PHS: Challenges in Organization case studies of PHS research and service programs for categorical diseases (Alzheimer's disease, substance-abusing pregnant women, and dopamine research related to schizophrenia and Parkinson's disease). In addition, the committee commissioned or staff prepared ten background papers on PHS agency and institute activities that were thought to be most sensitive to organizational structure. In the course of the study, seven task forces met, well over 150 interviews were conducted, and five full committee meetings were held. The committee's recommendations fall into several categories: organizational goals and missions of PHS agencies; management of research and services programs including effectiveness of planning and priority-setting processes, demonstration programs, and information dissemination efforts; organizational capacity and program placement and replication and duplication of research projects and programs. ORGANIZATIONAL GOALS AND MISSIONS Lack of clarity about the services mission of the PHS seems to be a more important factor than organizational structure in problems relating to the administration of services development and demonstration (treatment or prevention) programs. To facilitate accountability within the PHS regarding the objectives of services development and demonstration programs, the committee recommends that the Secretary further clarify the services mission of the PHS and of the agencies that administer programs related to development of the structure and delivery of services. Services programs should be given stability, including stability of organizational location, financing, personnel, and other resources. When responsibility for research and services development and demonstration programs for a single problem is divided among several agencies, however, the difficulties of communicating and collaborating across agency boundaries can inhibit success. The committee recommends that the Assistant Secretary for Health take responsibility for assessing and enhancing the integration of program objectives related to the services mission across agencies in the PHS. It is the impression of many science administrators in federal agencies, as well as other scientists interviewed for this study, that in the past five or ten years the research programs of ADAMHA institutes have benefited from an increasingly singular research focus.

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Research and Service Programs in the PHS: Challenges in Organization In case studies and interviews conducted for other background papers, the suggestion was made (almost uniformly by science administrators) that—at the level of institutes, bureaus, and offices—co-administration of research and service programs can retard the productivity of both programs through dilution of time, energy, and financial resources and increased difficulty in leadership recruitment. Given the complexity of administering federal research and service programs, functional organization (i.e., the administration of research, services development, and prevention programs by three separate agencies, namely NIH, HRSA, and CDC) can be helpful in allowing for the development of specialized skills that lead to improved performance. Analyses conducted for this study and previous studies suggest that, while the administrative and political dictates of research and service programs differ (and, therefore, specialization may be useful), these differences often result in conflicting if not mutually exclusive priorities. These analyses point out the need to pay attention to jurisdictional disputes and overlapping responsibilities and, to avoid fragmentation in the implementation of policies and programs, the need for a focused effort to increase collaboration across research and service programs in the PHS. The committee recommends that below the agency level, research and services programs be administered and conducted by separate institutes or offices that have substantial expertise in the specific substantive and functional area. In cases where ADAMHA institutes currently have responsibility for treatment services demonstrations, service development, or block grant compliance programs, for example, such programs might be placed more appropriately in an organizational unit that currently has responsibility for similar programs, along with staff of sufficient expertise in the substantive area to manage the programs effectively. Analyses conducted for this study suggest that at the agency level, there are few significant differences in the functioning of similar kinds of research programs in NIH and ADAMHA that can be attributed to organizational structure. Research conducted through institute programs in ADAMHA appears to function in a fashion comparable to research programs administered in NIH. Research allocations are a more complicated question. On the one hand, NIH and ADAMHA have increased funding for biomedical research by similar amounts over the past 10 years; this does not support the perception that research has suffered within a categorical agency (responsible for both research and service programs) in comparison with a functional agency such as NIH. In fact, in the last 5 years it

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Research and Service Programs in the PHS: Challenges in Organization appears that funding for research has fared somewhat better in ADAMHA than in NIH. On the other hand, over a longer period of time, perhaps 20 years, the data also suggest that research allocations to ADAMHA and its predecessors suffered during the 1970s and only began to recover following passage of the block grant legislation and internal reorganization of ADAMHA. A number of science administrators and science policy constituency groups interviewed for this study suggested that research allocations to ADAMHA in the 1970s may have been hurt by negative perceptions of early social research and that recent research allocations may have been helped by perceptions of drug abuse and AIDS as major social problems as well as by exciting research findings. The longer one's view, the more susceptible the data are to contradictory interpretation. The committee encountered no persuasive evidence that overwhelmingly supports any specific agency structure, and it therefore recommends that agency-level organization not be used as the basis for deterring or encouraging reorganization. If reorganization of current agency structure is considered, it should be justified purely on policy grounds. PLANNING AND PRIORITY SETTING An important question for this study was whether specific mechanisms existed for relating the program objectives of research, prevention, and services development and demonstration programs both within ADAMHA and among the relevant agencies of the PHS. There is no single, coherent system that can be labeled priority setting; rather, priorities are determined as a result of myriad discrete activities involving Congress, the administration, the research and service communities, and individual program managers. At the level of Congress and the administration, the annual budget is the only plan. The committee found that the budget planning and review process treats research separately from services but that the research programs of NIH and ADAMHA are treated similarly. Strategic planning for scientific efforts has been important in the NIH institutes. Many institutes use selected portions of their strategic plans in order to contribute to broader agency and PHS plans and to guide preparation of budgets. Strategic planning has functioned more effectively in institutes that have an established knowledge base and stable mission than it has in institutes where the science is in a state of flux. Interviews in HRSA and ADAMHA revealed that the planning process in their offices and institutes is less ordered, and linkages

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Research and Service Programs in the PHS: Challenges in Organization with agency and PHS plans less structured. Although institute planning processes within ADAMHA appear admirably flexible, that flexibility may also allow the planning process to be subject to frequent changes of direction and focus, thus failing to provide continuity to institute and bureau programs. The committee recommends that all agencies within the PHS and each research institute be mandated to develop five-year plans, the process for which shall be reviewed by the Assistant Secretary for Health, and that plans be updated (with changes only) on a yearly basis. The committee notes that it is as important for five-year plans to specify program goals and objectives as it is that they be linked with and revised according to an annual budget. DEMONSTRATION AND INFORMATION DISSEMINATION PROGRAMS Conflicting expectations on the part of Congress and federal agencies have created some difficulties in the administration of demonstration programs. The problems that arise for federal agencies from conflicts between the agendas and expectations of Congress and the administration can be formidable. The administration and Congress often fail to define their goals clearly, and when they do define their goals with some precision, the goals often conflict. Even when the administration, Congress, and agencies are in some agreement about their goals, they may disagree about how to accomplish what they want to accomplish. Although the administration and Congress are powerful in setting the agenda for federal agencies, they do not necessarily control the alternatives among which choices are made. These conflicts can result in insufficient resources being applied to a problem, inability to develop appropriate organizational structures for implementation, simple failure to initiate a program, or a deluge of demands for clarification of new legislation in the face of established, perhaps long-standing, policies that move in the opposite direction. Examples of the effects of conflicts among the expectations of the administration, Congress, and agencies include failure to replicate successful demonstrations across multiple sites prior to implementation and failure to evaluate the effectiveness of implementation prior to national dissemination. Interviews indicate that the amount of funds available for replication and evaluation will affect whether new practices and system innovations will be disseminated appropriate-

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Research and Service Programs in the PHS: Challenges in Organization ly—that is, after having been shown to be cost-effective and efficacious. Replication and complementarity are essential as part of the research process. The committee recommends that replication, which is vital to basic and clinical research but which has not been considered a central element of demonstrations, be ensured in new and ongoing research demonstrations following single-site experiments and prior to implementation and national dissemination. A related question is whether there might be fewer obstacles to the translation of research findings into service programs in a single agency than when translation requires collaboration across a number of agencies. According to program administrators in ADAMHA as well as CDC, there is no formal link between the demonstration and block grant programs they fund, even though they are often administered by the same state and local agencies. A number of models of the research –services continuum have been developed by PHS agencies and institutes, but the analyses for this study encountered little evidence of specific mechanisms for identifying the emerging results of clinical research or demonstrations that might serve as a basis for initiating intervention trials or for dissemination and introduction into state programs through the block grant program. To ensure that the programmatic objectives of demonstrations are achieved, the committee recommends that a research program be initiated within the PHS to determine effective dissemination mechanisms for demonstrations and the results of health services research. Interviews with constituency groups noted that state agency officials often are unaware of the existence of federal demonstration projects in their states, particularly those funded by ADAMHA institutes and offices. In many instances, lack of consultation and collaboration has led state agencies to be reluctant to appropriate the funds to continue demonstrations, even successful ones, after federal funding has ended. The committee recommends that a plan for incentives for translation of successful demonstration findings into the structure and delivery of services be accompanied by opportunities for state review and comment on all types of federal demonstration applications. Potential sources of postdemonstration funding for successful demonstrations (i.e., federal, state, local, and private sources) also should be explored prior to initiating a demonstration project. Articles in scientific journals targeted to researchers may not meet the needs of potential users of successful demonstrations. Previous studies, as well as the committee's own case studies, found that the

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Research and Service Programs in the PHS: Challenges in Organization characteristics of individuals and organizations using new practices have an important influence on how the results of research are received and used. For instance, nonprofessional, community-based service providers may require access to training, technical manuals, or technical assistance in order to be able to adopt the results of successful demonstrations. The committee recommends that the responsibility for technical assistance and clinical training programs for professionals and nonprofessionals, and the resources to carry them out, be part of the explicit mission of agencies that fund and administer operating programs (e.g., HRSA, the Indian Health Service, and ADAMHA). In the course of gathering information and deliberating on the central issues of this study, the committee reached other conclusions closely related to its primary charge. Serious questions were raised about how decisions are made about where to locate programs in the PHS and about the effects of frequent movement of programs. The committee recommends that, when Congress authorizes new research or services programs, it consult with the Secretary of Health and Human Services to determine, within a brief period of time, the appropriate locus of program administration within the department. When a new or significantly expanded function is authorized, priority should be given to providing sufficient staff and financial resources to carry out the function. DUPLICATION, REPLICATION, AND COMPLEMENTARITY Information gathered for this study suggests that wasteful duplication of basic and clinical biomedical research is not a problem in the PHS. Lack of coordination among demonstration projects being funded by institutes and offices within ADAMHA and across agencies in the PHS constitutes more of a problem than duplication. The committee found it extremely difficult to address the question of duplication because of the lack of a standard nomenclature within PHS agencies and institutes for classifying research and service programs and projects. The lack of an agreed-upon nomenclature presents a barrier to planning, evaluation, public access to information, and accountability within the PHS. The committee recommends that an interagency task force be formed to develop a standard nomenclature for classifying basic and clinical research, demonstrations, and service development activities

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Research and Service Programs in the PHS: Challenges in Organization across PHS agencies. The committee further recommends that the National Library of Medicine be mandated and given appropriate resources to carry out whatever research is necessary for the development of this standard nomenclature. FINAL THOUGHTS As this report was being readied for publication, both Congress and the Department of Health and Human Services (DHHS) announced plans to reorganize ADAMHA. The report itself and the background papers prepared for the committee provide significant information that can be used by Congress, the Secretary of Health and Human Services, the Assistant Secretary for Health, the agencies involved, and constituency groups to guide that reorganization. The responsibilities of PHS agencies and officials have grown in substantive, technical, and administrative complexity over the past 20 years, often without regard for order or consistency. Interviews conducted for this study leave little doubt that the complexity of administering an agency such as ADAMHA, with two or more missions of equal importance, adds a magnitude of difficulty to the task of an agency administrator. Confusion and conflict over the interpretation of an agency's minions or the structures for carrying them out (which have occurred both in ADAMHA and HRSA) raise the level of difficulty even further. Stability of organizational mission and program placement is important to a wide range of constituency groups. Analysis of constituency group relations with federal agencies suggests that instability undermines perceptions of the reliability of government operations, increases barriers to and frustration with development and maintenance of working relationships with agencies, and constrains group involvement with federal agencies. Changes in organizational arrangements are a particular problem when they are perceived as eliminating or reducing the standing of programs that have served as focal points for constituency group concerns. These arrangements are a particularly acute concern in the substance abuse and mental health fields, where organizational missions and arrangements have been less stable. Finally, structural reorganization often has little or no impact on the actual delivery of services, as was pointed out in the analysis of linkage mechanisms within PHS agencies that was prepared for the committee:

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Research and Service Programs in the PHS: Challenges in Organization Many of the reform efforts of the past have rested on the assumption that change can be devised and implemented at the administrative level, which will provoke change at the point of service delivery. The experience of these years, however, suggests that such a relationship may be an act of faith rather than demonstrated by evidence. While there may be strong and important reasons for making administrative changes (e.g., reorganization, joint planning efforts), the world of service delivery is rarely affected by forms or styles of organization. Rather, it is the nature of the policies to be administered and the resources available which impact the system at the point of service delivery.