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Chapter 3
NIH AND THE HEALTH POLICY ENVIRONMENT
The Need for Communication and Coordination
If NIH ant its seater agencies in the Public Health Service are to
be responsive to health needs and to promote scientific excellence,
there must be clear channels of communication between them, the public,
and Congress to make sure that policies are coordinated and well in
tune with health research needs. Such communication has always taken
place, but generally in a highly informal manner. It is now time, the
committee believes, to formalize certain aspects of this process. In
particular, the process must respond to changes in recent years con-
cerning the scope of health research and governmental patterns and
practices, which together have increased external pressures for
organizational change within the Public Health Service.
The Scope of Health Research
Many of the most recent proposals for organisstional change at NIH
reflect interests in improving and strengthening research areas at the
boundaries of NIH's current mission. In recent years, for instance,
there have been legislative and other proposals for a National Institute
of Nursing Research and a National Institute of Public Health. There
also have been proposals for the transfer into NIH of the National
Center for Health Services Research, the National Institute for
Occupational Safety and Health, the National Center for Health
Statistica, and the National Institute of-Mental Health. Ant there
have been calls for NIH to do more on technology assesement and
transferring research results into practice.
These "boundary isauea" share many common feaeurea. First, they
are all examples of health research, broadly defined. As acientiata'
perceptions about the determinants of health widen, as the federal
government's role in the provision of health care expands, and as the
nation becomes more concerned about health care expenditures, health
research that include a more than traditionally conceived biomedical
research is increasingly recognized as necessary to the nation'a well-
being. Second, although the research mission of NIH does not totally
include any of the research arena mentioned above, it also toes not
totally exclude them. Third, not all of these areas enjoy the same
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25
prestige and visibility as does the biomedical research now carried out
by NIH. Finally, some of the agencies proposed for transfer have
regulatory or health service delivery mi88ion8 that, while of great
importance, are distinctly different from that of NIH.
Because of the complexity of the individual cases, it was not
possible for the committee to decide whether the nation'a needs would
be best served by expanding the NIH mandate to include particular
areas, by having them addressed by other agencies, or by devising
improved methods of coordinating functions that inevitably cut across
organizational lines. The committee believes that such boundary issues
and the challenges of improved coordination and priority setting are
crucial both for NIH and the integrity of the federal health structure,
and that there must be a mechanism to assist the Assistant Secretary
for Health to investigate these matters systematically and to propose
workable solutions.
Governmental Patterns and Practices
For many years, Congress has been highly supportive of NIH and
deeply involved in shaping its research priorities in broad terms.
Over time, however, the nature of the relationship between NIH and
Congress has changed.
In the 1950s and 1960s, the relationship between NIH and the public
was focused in Congress by close working relationships among Senator
Lister Hill, chairman of the authorization committee and the
appropriations subcommittee in the Senate with authority over the
budget of the NIH; Representative John Fogarty, chairman of the
appropriations subcommittee in the House of Representatives; and James
Shannon, the Director of NIH.27 Public interest, to a large extent,
was exerted through the lon~-term involvement ant commitment of Mary
Lasker and her associates.2 The result was unified and organized
public and congressional interest in NIH. This strong central focus
depended partly on the personalities involved, but also on the way that
congressional affairs were conducted in those years.
Since then, these relationships have changed. First, the members
and committees of Congress now have staff numbering about 17,000, more
than five times as many as in 1947.29 This has led to increased
involvement in day-to-day Executive Branch activities, and the
knowledge, ability, and incentive to write very specific directives
into law or legislative reports. Second, partly because of legislation
enacted in the pant decade, authorization committees as well as appro-
priations committees now have substantial impact on NIH activities.
Some of the institutes, for instance, must now be periodically
reauthorized by Congress. The result of these and other changes in
governmental operations is that NIH management has gradually become
more fragmented ant less coordinated.
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26
In response to constituent pressures and sometimes because of a
perception that NIH would not initiate action on its own, Congress
often has proposed new institutes or other organizational changes to
emphasize particular diseases or health problems. NIH has consistently
opposed these changes, ant thus has acquired an image of being opposed
to Innovations proposed from outaide~the agency. Organizational
changes should not be the only means, or even the primary means, of
Implementing changes in research priorities. Therefore, there should
be an effective mechanism for judging the need for organizational
changes as a means of addressing priorities, using the criteria
suggested above, and for suggesting appropriate alternatives.
The Health Science Board
To address there changes in the NIH policy environment, and to deal
with the increased pressures for organizational change documented in
the previous chapter, the committee recommence:
1.
A Health Science Board should be established in the Department
or nealtn and Human Services to oversee the health research
organization, missions, priorit ies, ~e-
ment of the several elemen ~ e
National Institutes of Health; the Ce~;~;
~ Drug Abuse and
~ _~8
Administration; the Nationa ~—
the National Center for Health Services Research.
2. On the basis of periodic reviews, the Health Science Board
should advise the Secretary of
through the Assistant Secret ~
~ these
elements, such as the initiatio ~
of the National Institutes of ~ e
Public Health Service, or the reassignment of responsibilities
among institutes and units.
3.
4.
ix members
om a
~ i~ t~~
National Acat
Appointments should be mate for a term of six years, with
one-third of the board' 8 membership r~nl Abbe ^~ - a ~ ~^ ,,^~_o
ana_rne reappointment of members limited to one additional
. _
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27
5. Members of the Health ~ Id be selected on the
basis of a judicious combination of scientific experience,
capacity for sound judgment, and knowledge of health policy
i88ue8 and the principles of public management.
6.
The Health Science Board should elect its own chair, meet at
least four times a year and additionally whenever requested by
the Assistant Secretary for Health, be assigned its own staff
and have a defined budget, and have the ~ es
to establish study groups or panels to assist
e
moo 8 ~on.
The Health Science Board should report annually to the
man Services through the Assistant
_ ~
secretary :or Health.
,
The Health Sciences Board is intended to communicate public
perceptions of health research needs to the scientific establishment
and to assure the public that these needs are being adequately and
appropriately addressed. In particular, the board would be concerned
with the boundaries of the research missions of NIH and the rest of
the agencies of the Public Health Service, and with proposals for major
organizational changes in those agencies.
The board's role is, in many respects, like that of the trustees or
regents of a public institution. The National Science Foundation's
National Science Board, the Smithsonian Institution's Board of Regents,
and the regents of many state universities, for instance, are extremely
effective in guiding and protecting these institutions. But unlike
true teen or regents, the Health Science Board would not have the
ultimate responsibility for the agencies under its aegis; this
responsibility belongs to Congress and the Secretary of Health and
Human Services.
The board would, however, prepare an annual report that would be
carefully read by Congress and various scientific and public interest
groups as well as the Executive Branch agencies. The publication of a
report would make the board's views widely known, and its broad public
exposure would ensure that the board members take their responsibility
seriously. Six-year terms and frequent regular meetings would make
them fully aware of the important health and health science issues
under discussion.
Because of~the proposed board's role in communicating with the
public and serving as an independent review group, it is essential that
its members be widely respected persons, both scientists and
non-scientiste. The committee feels that appointment by the Secretary
of Health and Human Services is necessary to enhance the prestige and
sense of responsibility of the board and its members. The members must
have individual expertise as scientists and administrators, and
knowledge and interest in health policy issues. Partisan political
considerations should have no place in the choice of members for the
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28
board. In order to guarantee excellence in appointments to the board,
the committee recommends that the National Academy of Sc fences and the
National Academy of Public A~miniatration (both of which have congres-
sional charters and responaibilities to advise the federal government
on matters within their expertise) be involved in the nomination
prOCe88 e
The members of the board should be capable of considering the
national interest in health research in the broad sense. They should
not be chosen to represent any particular group or constituency. In
order to promote the development of conaenaua and to emphasize the fact
that the members are not representatives, the committee recommends that
the board have only six members.
Successful institutions tend to cling to their past successes and
resist change. Periodic review by an independent outside group can
help counter this tendency. In this respect, the Health Science Board
could be a potent force for organizational renewal and vitality for NIB
and the other agencies of the Public Health Service. The committee
recommends that, to preserve its independence, the board elect a chair
from among its members, and have its own budget and sufficient staff to
prepare agenda and compile background materials. Many of the issues
that would come before the board, such as proposals for new institutes,
terminations, or tranafera, require more intense and thorough attention
than the board alone could provide. In such cases, the board must have
the authority ant resources to establish appropriate study groups or
pane 18 e
To deal with the full range of health research, the Health Science
Board must be located in the Public Health Service of the Department of
Health and Human Service a. Many agencies ant departments of the
federal government have a health research mission, but much of this
research--almose 80 percent in 1982--is concentrated in the Public
Health Service.30 As the fiat of the Public Health Service units
indicates, the range of issues covered and approaches used is quite
broad. And unlike other governmental departments, the Public Health
Service has the improvement of health as its central mission.
For these reasons, the Public Health Service is the key locus of
coordination and control of health research in the United States. But
because many of the organizational iasuea described above concern the
boundaries of the research missions of the NIB and the rest of the
agencies of the Public Health Service, the committee feels that more
effective coordination of their missions is necessary. The Health
Science-Board proposed here is intended to provide such coordination.
Organizational issues are prominent among those that involve the
total mission of the Public Health Service. These include the creation
of new institutes at NIH and the transfer of units or functions among
the elements of the Public Health Service. Because of its broad
perspective, the board would be able to provide useful and unbiased
advice on such matters, and to interpret the criteria suggested in the
previous chapter.
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29
The Secretary of Health and Human Services, through the Assistant
Secretary for Health, has the responsibility for managing and setting
long-tenm policies for the Public Health Service research agencies.
The board should not become involved in day-to-day management of the
research agencies, but rather would advise the Secretary through the
Assistant Secretary on issues that involve the spectrum of agencies of
the Public Health Service on the full range of their research missions.
The Health Science Board would advice on issues that cross agency
boundaries as now defined. Prevention research is one example.
Research on health promotion and disease prevention-necessarily
includes a spectrum of approaches ranging from basic to applied,
drawing on the biomedical, behavioral, and social sciences. Most of
the Public Health Service agencies, including NIH, have expertise and
explicit responsibilities for prevention research an part of their
basic missions. Thus a single institute or agency cannot coordinate
this research. But coordination is necessary, and the Health Science
Board court help to ensure that the government's total approach is
complete, coordinated, and appropriate.
The board is not intended to replace the current Advisory Committee
to the Director of NIH, or-other advisory committees in NIH or other
Public Health Service agencies. These have important roles to play in
overseeing the research programs of individual agencies. Instead, the
board would ensure that the individual agencies are making adequate
contributions to the total effort.
The committee known of no alternative that would be more effective
in serving these purposes than a board at the level of the Assistant
Secretary for Health. No advisory board or other entity in any of the
Public Health Service agencies would have the necessary perspective or
the credibility to deal with such issues. At a level higher than the
Assistant Secretary, health research is only one of many important
issues, and the board's advice would not get full attention. And
because of its permanence, the board would be more effective than many
past ad hoc efforts to review the structure, research mission, or
_ ~
priorities of NIH and its sister agencies e These include many
congressional investigations, the Bayne-Jones committee in 1956, the
Wooldridge committee in 1965, the Presidene's Biomedical Research Panel
in 1976, the National Conference on Health Research Principles in 1978
and 1979, and the committee writing this report.
There have been proposals for similar oversight mechanisms in the
past. The closest example is the President's Council for the Health
Sciences, proposed by Senator Edward Kennedy in 1979. This council
would have prepared for Congress and the President a five y ear plan for
funding health sciences research. The committee feels that the
preparation of budgets is the responsibility of the officials of the
Department of Health and Human Services , the Office of Management and
Budget , and Congress. The Health Science Board, however, would be able
to provide advice on these matters, especially on the determination of
priorities among the various agencies and broad areas of health science.
Representative terms from entire chapter:
health research
