Over the past 25 years, questions have often been raised about the role of the Public Health Service (PHS) in funding, planning, and administering research and services development and demonstration programs, and about how the PHS is organized to carry out its research and services development functions. This study was motivated by a number of specific concerns raised in the past 5 years by constituency groups; by members of Congress; by the leadership of the National Institutes of Health (NIH) and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA); by grantees of the two agencies; and by analysts of federal research and development activities. For example:

• Constituency groups (grantees, advocacy groups, professional associations, etc.) have raised questions about priorities and levels of funding for either research or service activities, and about how research and service development and demonstration programs fare under a single administration such as ADAMHA.

• The leadership of NIH and ADAMHA and professional groups have questioned whether a single director or administrator can effectively manage an agency responsible for both research and service activities.

• Members of Congress have expressed concern about reductions in the services components of ADAMHA (reductions that seem to reflect a change in ADAMHA's congressionally authorized mission) and about the need for increased attention by NIH to the transfer of the results of basic research into clinical practice.

The Committee on Co-Administration of Service and Research Programs was asked to evaluate and discuss the advantages and

disadvantages of administering service programs in conjunction with administering research and research-related activities in the PHS. The committee consisted of 14 individuals appointed by the president of the Institute of Medicine (IOM) with the concurrence of the president of the National Academy of Sciences. The committee met five times in the course of 15 months to develop a study plan, analyze the issues, and make recommendations. The project officer for the study from the Office of the Assistant Secretary for Health and the liaison committee of officials from NIH, ADAMHA, the Health Resources and Services Administration, the Centers for Disease Control, and the Office of the Assistant Secretary for Planning and Evaluation helped the committee gain access to the information necessary for the study.

This study, like previous studies of the organization and management of research and service programs in the PHS, attempted to respond to specific questions that involved issues of structure, leadership, and polities. The committee consulted the organizational and public administration literatures, as well as the literature on management of research and development programs, in establishing a framework for the study. This report is an attempt to pull together various ideas current in PHS agencies and to explore the apparent relationships (or lack thereof) between research and service programs in specific cases examined for this study.

In order to develop a study methodology and gather information, the committee established seven task forces. A member of the full committee either chaired or was a member of each task force. The task forces included, in total, 23 additional people (Appendix C ); their reports have strongly influenced the deliberations of the full committee as well as many elements of this report.

The committee and task forces relied on a series of activities to gather information. Case studies and background papers were either commissioned or written by staff. The committee also reviewed many previous studies of ADAMHA, NIH, and other federal agencies, as well as numerous policy papers on organization and public management issues. In addition, after developing a classification scheme, research grants and services development and demonstration programs and projects were classified (within case study areas) for selected years between 1975 and 1989 to assess changes over time in the research and services portfolios of agencies and institutes.

During the course of the study, more than 150 interviews were conducted by staff and consultants. Interviews conducted with current federal officials included agency directors, policy analysts, directors of budget and planning offices, administrators of research and service development and demonstration programs, and scientists. In addition,

the directors, presidents, and staff of more than 25 constituency groups were interviewed. The interviews for the case studies and commissioned papers revealed a number of concerns about basic and clinical research training programs, health care financing and reimbursement policies, the long-term impact of dissemination of research findings on changing clinical practice patterns, and the size of allocations to both research and services programs in the PHS. These concerns deserve the full attention of the PHS but are beyond the committee 's charge and thus are not dealt with in detail in this report.

Although the committee and task forces tried to be as thorough as possible in gathering objective information, much remains a matter of judgment. In the end, the findings and recommendations of this report are the product of a synthesis of objective analyses conducted by staff and consultants, the informed opinion of a wide range of respondents, committee members' extensive experience, and committee discussions.

Notwithstanding the many challenges presented by this study, committee discussions were at the same time both enthusiastic and deliberate. The resulting recommendations address a number of important issues. Throughout the course of this study, the committee benefited from the efforts of the task force participants, all of whom made significant contributions to the study. Important and necessary background materials were provided by John Burckhardt, the study's project officer, and by the members of the liaison committee. Data on grants, without which the study could not have proceeded, were provided by staff in the Division of Research Grants at NIH. The committee is grateful for the valuable contributions and insights of case study writers Kathleen Stratton, Lorraine Klerman, and Carol Blixen; the indispensable work of the writers of commissioned papers, Ruth Hanft, Beryl Radin, Jeffrey Fox, Phyllis Kaye, Sarah Williams, and Richard Schmidt; and the significant contributions of consultant Bob Walkington.

The committee could not have met its charge without the expertise and dedication of staff of the Institute of Medicine. The committee wishes to thank the director of the Division of Health Sciences Policy, Ruth Bulger, for her interest and useful suggestions throughout the study. The committee is especially indebted to study director Mady Chalk and her astute management of the entire effort. Her broad knowledge of issues and people, coupled with good judgment, fairness, enthusiasm, and patience moved the study forward efficiently. Kathleen Stratton, the associate study director and a case study writer, with her clarity of thinking, commitment, and good

humor, made invaluable contributions to the study. Catharine Chetney, research assistant, expressed interest in specific parts of the study that led to her assuming responsibility for one portion of it. Her willingness to help with the many tasks requested of her was especially helpful. All staff worked long and hard within extraordinary time constraints, given the scope of the study, to accomplish the committee 's task. Beverly Proctor, Louise Gillis, and division secretary Rita Gibson made the meetings for the study in Washington and California comfortable for members and guests of the committee, as well as providing excellent secretarial support.

Steven Beering, Chair

Committee on Co-Administration of Service and Research Programs of the National Institutes of Health, the Alcohol, Drug Abuse, and Mental Health Administration, and Related Agencies

Research and Service Programs in the PHS: Challenges in Organization