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September 27, 2022

Why NIH Should Reinvigorate an Advisory Board on its Performance and Organizational Structure

For many years, observers have noted that NIH’s structure and organization isn’t necessarily the most rational. Why are there 27 Institutes and Centers (ICs) that usually concern particular diseases and body parts? For example, why is nursing research or alternative medicine a major focus rather than nutrition?

It’s not because of any rational and systematic discussion of how to organize biomedical research. Instead, it’s because of an ad hoc process over many decades in which prominent congressmen and/or patient groups were able to add a new center or program devoted to their particular interest.

The result, as an NIH insider is known to say, is that NIH’s organization is “so crazy that only Congress could have come up with it.”

We need to reinvigorate an existing method for regularly assessing NIH’s performance and advising Congress on how best to organize NIH itself: the Scientific Management Review Board.

That Board was created under the NIH Reform Act of 2006, which passed virtually unanimously.

Its purpose was to give advice to Congress, the HHS Secretary, and the NIH Director on how to exercise their existing ability to 1) establish new Institutes (which can happen with the HHS Secretary’s recommendation unless Congress rejects it); 2) reorganize any existing Institute or even abolish it (again, this happens with the HHS Secretary’s recommendation unless Congress rejects it), 3) reorganize the Director’s Office, or 4) reorganize particular Institute-level activities.

The Board’s actual activities were to review the “research portfolio” of NIH in order to determine its “progress and effectiveness,” including the “allocation” across different activities; determine the “pending scientific opportunities, and public health needs,” with respect to NIH research; and analyze any potential impacts from reorganizing NIH.

Perhaps most powerfully, the Board’s recommendations would go into law automatically, unless the NIH Director and/or Congress objected in some circumstances.

At least in theory, this Board could have been extremely effective at regularly rethinking how we organize biomedical funding in the US.

But for some reason, this Board’s full advisory authority has never been used. It has never issued an NIH-wide report on the full spectrum of issues described above (most of its reports have been only on procedural issues and/or narrow issues pertaining to one area of research or one NIH center). It did issue a report basically recommending that the National Institute on Alcoholism and Alcohol Abuse be combined with the National Institute on Drug Abuse, but was vetoed by Francis Collins.

Someone who was involved with that process commented to me, “What a waste of time and emotion for many serious people–who with deliberative seriousness made the right recommendation (in my view). I was pretty disgusted and I can only imagine how alienating it was to the committee.  What Francis did instead was to use his ‘political capital’ to kill NCRR, which was functioning just fine, in order to start NCATS–which does not seem to have been worth the effort or tradeoff.”

In any event, the Board has done nothing at all since 2015. This explains why certain members of the Board were surprised when I reached out to them—they didn’t remember having been on the Board in the first place! One Board member (Nancy Andrews) blamed Francis Collins for the inactivity: As she told STAT, “I had the sense that we were asking questions in areas that they didn’t really want to get into, and I suppose Francis in particular didn’t really want us working on.”

Inspired by the STAT piece, some members of Congress recently sent a letter to the acting NIH Director Larry Tabak asking him to explain why the NIH hadn’t convened the Board since 2015, how it had used the appropriations for the Board, and more.

The NIH Reform Act already put a good idea in place. As Elias Zerhouni (the NIH Director at the time) told me, NIH needed a process to regularly assess how its overall portfolio is doing, and whether to reorganize so as to better achieve its objectives—just like any major institution, company, etc.  

That makes perfect sense. It’s not to say the process will always work, but we won’t know until it is fully used for the first time.

Together with the Brookings Institution and the Institute for Progress, the Good Science Project is sponsoring a small workshop next month to bring together both policymakers and scholars who have studied institutional reform, in order to advance this issue. We hope that Congress and NIH will more regularly engage in a detailed consideration of NIH’s strategy and structure.