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Institute of Medicine (US) Committee on the Review and Assessment of the NIH’s Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities; Thomson GE, Mitchell F, Williams MB, editors. Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business. Washington (DC): National Academies Press (US); 2006.

Cover of Examining the Health Disparities Research Plan of the National Institutes of Health

Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business.

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4Budget and Finances

The Committee assessed the Strategic Plan budgets, recognizing their importance 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 during 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 uniform 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 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 contributing 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 considered 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 disparities 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 populations: low socioeconomic status and rural populations. Section 485(d)(1) of the enabling minority health and health disparities legislation defines a health disparity 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.”

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BOX 4-1

Minority Health Report. Minorities are defined by statute as American Indians/Alaskan Natives (including Eskimos and Aleuts), Asian Americans, Native Hawaiians and other Pacific Islanders, blacks, and Hispanics (i.e., individuals whose origin is Mexican, (more...)

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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 (more...)

The definitions of applicable research activities for basic research, infrastructure, 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 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 appropriated $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 disparities 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 methodology. 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 (figures for health disparities were not reported in 2000; Table 4-3).1 With the application 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 originally 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.

TABLE 4-1. Percentage of Total Appropriation Used for Minority Health Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1999–2004.

TABLE 4-1

Percentage of Total Appropriation Used for Minority Health Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1999–2004.

TABLE 4-2. Annual Expenditures on Minority Health Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1998–2004 (Dollars in Millions).

TABLE 4-2

Annual Expenditures on Minority Health Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1998–2004 (Dollars in Millions).

TABLE 4-3. Annual Expenditures on Health Disparities Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1999, 2001–2004 (Dollars in Millions).

TABLE 4-3

Annual Expenditures on Health Disparities Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1999, 2001–2004 (Dollars in Millions).

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 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.

FIGURE 4-1. Percentage of total NIH budget funding minority health and health disparities research activities between 1999 and 2004.

FIGURE 4-1

Percentage of total NIH budget funding minority health and health disparities 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 (more...)

TABLE 4-4. Percentage of Total Appropriation Used for Health Disparities Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1999, 2001–2004.

TABLE 4-4

Percentage of Total Appropriation Used for Health Disparities Research Activities by the NIH Institutes and Centers (ICs), Fiscal Years 1999, 2001–2004.

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; 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 allocations. 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 largest change was for NICHD, which demonstrated a 40 percent drop in the previously reported allocation to health disparities research and almost a 50 percent drop for minority health research. Increases were seen for the National Institute on Aging, the National Institute on Deafness and Other Communication Disorders, and the National Institute of Dental and Craniofacial Research. Even after the application of the new methods, NICHD channeled comparatively large allocations 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, spending on minority health research kept pace with the doubling of the NIH budget that occurred between 1998 and 2003.

TABLE 4-5. Annual Appropriations of the NIH Institutes and Centers (ICs), Fiscal Years 1998–2004 (Dollars in Millions).

TABLE 4-5

Annual Appropriations of the NIH Institutes and Centers (ICs), Fiscal Years 1998–2004 (Dollars in Millions).

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.

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 commitment 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 the ICs’ priority processes. The ICs’ processes for establishing such priorities should be of concern to those responsible for the overall health disparities research and Strategic Plan program, as well as to other reviewers. Furthermore, information from such considerations could be the bases of arguments for additional 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 example, the general public, Congress, other government agencies, and organizations 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 institutions, community-based research, and specific outreach endeavors, such as communication 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 available 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 categories 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, research capacity, and communication also should be made available.

Footnotes

1

Amounts are not adjusted for inflation.

2

Budgets are compared in current dollars.

Copyright © 2006, National Academy of Sciences.
Bookshelf ID: NBK57056

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