FDA receives annual appropriations to conduct its medical product responsibilities; these appropriations include amounts derived from user fees paid by industry in connection with FDA activities. FDA’s medical product responsibilities include oversight of the safety and effectiveness of medical products marketed for sale in the United States, regardless of whether they are manufactured domestically or overseas. The agency’s role is far-reaching and its responsibilities include oversight of medical products both before and after they are marketed in the United States. Each year, the request for FDA’s resources is submitted to Congress as part of the President’s Budget request. FDA develops and submits supporting information for the request in the budget justification that is submitted to the subcommittees with jurisdiction over FDA funding as part of the annual appropriations process. This information reflects how FDA proposes to meet its mission, goals, and objectives and assists Congress in understanding whether FDA will require significant changes in levels of appropriations. Guidance issued by OMB, which assists the President in overseeing the preparation of the federal budget, directs agencies to incorporate the cost of fulfilling all statutory requirements and responsibilities in their submissions to OMB for consideration in developing the President’s Budget request. We have also issued guidance on the development of comprehensive and reliable resource estimates, which includes recognition of the basic elements of such estimates. For example, these elements include complete and reliable data, such as data on the agency’s current resources, workload and performance; provisions for program uncertainties; adjustment for inflation; recognition of any exclusions; and an independent review of the estimates. In fiscal year 2008, FDA’s funding totaled $2.2 billion. Of this amount, about $500 million was derived from user fees collected from industry and made available until expended. The remaining amounts, about $1.7 billion, were derived from the General Fund of the Treasury and available during fiscal year 2008. Both user fee funding and fiscal year appropriations are made available through the annual appropriations process. About $1.2 billion—over half of FDA’s total funding—supported its medical product programs, including about $750 million in fiscal year appropriations and about $440 million in user fee funding. Over half of this funding—$681 million—supported the drug program, while $234 million supported the biologics program and $275 million supported the devices program. FDA’s total funding is a small portion of federal government and HHS funding. In fiscal year 2008, the federal government’s funding totaled approximately $3 trillion, of which about $722 billion was made available to fund HHS activities, including those at FDA. These amounts reflect both discretionary spending and mandatory spending. (See fig. 1.) All of FDA’s programs involve discretionary spending. User fees are paid in connection with FDA’s drugs, biologics, and devices programs’ review of applications for new medical products and inspections of mammography facilities. The Prescription Drug User Fee Act of 1992 (PDUFA) was enacted to expedite the review of applications for new drugs and new biologics. PDUFA authorized FDA to collect user fees from drug and biologic sponsors, typically manufacturers, to support the process of reviewing new drug applications (NDA) and biologics license applications (BLA). Likewise, the Medical Device User Fee and Modernization Act of 2002 (MDUFMA) authorized FDA to collect user fees from device sponsors to support the process of reviewing applications for certain new devices. In both cases, FDA’s authority to collect fees and use the amounts collected must be provided in appropriations acts. Both PDUFA and MDUFMA require FDA to apply all user fee funding to support the agency’s process for reviewing applications for certain new medical products, and preclude the agency from using this funding for other agency activities. In fiscal year 2008, agency activities not funded with user fees included, for example, the agency’s oversight of the safety of human tissues, review of applications for generic drugs, inspections unrelated to the agency’s review of new medical products, and some postmarket safety oversight activities. PDUFA and MDUFMA user fee funding only partially covers FDA’s costs for reviewing applications for certain new medical products and associated activities. FDA is also required to use a specified amount of its fiscal year appropriations to support its review of these applications. Within FDA, three centers have primary responsibility for ensuring the safety and effectiveness of medical products. The Center for Biologics Evaluation and Research (CBER) is responsible for overseeing biologics; the Center for Drug Evaluation and Research (CDER) is responsible for overseeing drugs and some therapeutic biologics; and the Center for Devices and Radiological Health (CDRH) is responsible for overseeing devices and for ensuring that radiation-emitting products, such as microwaves and x-ray machines, meet radiation safety standards. Among other things, these centers evaluate the safety and effectiveness of new medical products prior to marketing, monitor the safety and effectiveness of marketed products, oversee the advertising and promotion of marketed products, formulate regulations and guidance, conduct research, communicate information to industry and the public, and set their respective medical product program’s priorities. In addition to the work of the three centers, the Office of Regulatory Affairs (ORA) conducts field activities for all of FDA’s product centers. Field activities include conducting inspections of domestic and foreign establishments involved in manufacturing medical products, examining medical products offered for import, and collecting and analyzing samples. Medical product program resources include funding for center activities and field activities. Center activity funding represents funding for the three centers—CDER, CBER, or CDRH—and field activity funding represents ORA funding for all medical product programs. As part of its oversight responsibilities, FDA reviews applications submitted by manufacturers for medical products they wish to market in the United States to ensure that new products are safe and effective, inspects establishments producing medical products to ensure manufacturing processes meet quality standards, reviews reports of adverse events to monitor the safety of marketed medical products, and examines advertising and other promotional materials to ensure they are not false and misleading. FDA’s oversight of medical product safety and effectiveness typically begins when medical product sponsors develop a new product, long before such products are marketed for sale. For example, FDA requires sponsors to submit an investigational new drug (IND) application before beginning clinical trials (studies in humans) of a new drug or new biologic. The IND application provides FDA with extensive information about the product, including safety and manufacturing information about the product, and outlines the sponsor’s plans for clinical trials. FDA assesses this preliminary information to ensure that the product is reasonably safe to begin studying in humans. While FDA does not issue a formal approval to the sponsor regarding an IND application, it can prohibit the start of a clinical trial by placing it on hold if, for example, the agency determines that human volunteers would be exposed to an unreasonable and significant risk of illness or injury. Sponsors often request guidance and feedback from FDA during the process of drug and biologic development. Before and during clinical trials, FDA may meet with sponsors to provide guidance on the design of the clinical trial. In addition, FDA may issue a written evaluation of particular aspects of a clinical trial—known as a special protocol assessment. FDA may also meet with sponsors after the completion of a successful clinical trial to discuss the information the agency would expect to see submitted to the agency for marketing approval. FDA’s approval is required before new drugs and biologics can be marketed for sale in the United States. To obtain FDA’s approval, sponsors must submit an application containing data on the safety and effectiveness of their new medical product as determined through clinical trials and other research. For example, sponsors must request approval for a new drug or new biologic by submitting an NDA or BLA. FDA reviews data included in these applications to determine whether the product is safe and effective for its intended use. FDA also examines proposed product labeling to ensure that it clearly states the condition and population the product is intended to treat. After completing its assessment of the information in the application and any subsequent submissions of additional information, known as application resubmissions, FDA determines whether to approve the product for marketing. After FDA approves a product, manufacturers requesting changes to product labeling, manufacturing, dosing, or usage must submit an application supplement to obtain FDA approval. In addition to its responsibility for approving new drugs prior to marketing, FDA approval is also required before generic drugs—drugs that are copies of already approved new drugs—can be marketed for sale in the United States. Sponsors of generic drugs may obtain FDA approval by submitting an abbreviated new drug application (ANDA) to the agency for review. The ANDA contains data showing, among other things, that the generic drug is bioequivalent to, or performs in the same manner as, a drug approved through the NDA process. Similar to its review of NDAs, FDA reviews information submitted in the application, including proposed product labeling. To request FDA approval of proposed changes to product labeling, manufacturing, dosing, or usage after a generic drug is approved, sponsors must submit an ANDA supplement. FDA is also responsible for overseeing the safety and effectiveness of devices. Devices are classified into one of three classes—class I, II, or III—based on the level of risk posed to the patient or user and the controls necessary to reasonably ensure safety and effectiveness. Class I devices are those that pose the lowest risk, and class III devices are those that pose the highest risk. Some devices are subject to one of two types of FDA review before they may be marketed for sale in the United States. Some class II devices are required to obtain FDA clearance through a premarket notification process, whereby a sponsor must demonstrate to FDA that the new device is substantially equivalent to a device that FDA previously approved or cleared for marketing. In contrast, class III devices are generally required to obtain FDA approval through a more stringent premarket approval process, whereby a sponsor must provide evidence, typically including clinical data, to demonstrate with reasonable assurance that the new device is safe and effective. As with new drugs and biologics, FDA’s review of these applications includes an assessment of product labeling and usage. FDA is required to review certain medical product applications within specified time frames. For example, FDA is generally required to review NDAs, BLAs, and ANDAs within 180 days of receipt. PDUFA also established performance goals to speed up FDA’s process for reviewing NDAs and certain BLAs. These performance goals can be grouped into three main categories—those related to the speed at which the agency (1) reviews applications and supplemental materials, (2) schedules and holds meetings with sponsors, and (3) issues written guidance as requested by sponsors. Multiple performance goals exist within each of these broad categories. For example, one performance goal is that FDA review and act on 90 percent of certain NDAs and BLAs within 10 months of their receipt; another is that FDA schedule 90 percent of certain meetings with sponsors within 30 days of receiving the sponsor’s meeting request. In addition, MDUFMA also established similar types of performance goals related to the timeliness of FDA’s process for reviewing applications for new devices subject to the premarket approval and premarket notification process. As part of its oversight responsibilities, FDA conducts inspections of domestic and foreign establishments. Specifically, FDA conducts inspections of clinical trial sites to ensure the protection of human subjects and the accuracy and validity of clinical trial data reported to the agency. FDA also inspects medical product manufacturing establishments to ensure that manufacturing processes adhere to current good manufacturing practices requirements and regulations. Inspections of manufacturing establishments may occur before medical products are marketed in the United States. To ensure continued adherence to current good manufacturing practices requirements, FDA may also inspect establishments after the product is on the market. FDA is required to inspect certain types of establishments with a particular frequency; however, requirements governing the frequency of these inspections differ. For example, FDA is required to conduct inspections of certain types of establishments every 2 years—including domestic drug and device manufacturers, as well as domestic blood banks. However, there are no comparable requirements regarding the frequency with which FDA should conduct inspections of other types of domestic establishments, such as domestic human tissue banks, or some foreign establishments, including those manufacturing drugs and devices marketed for sale in the United States. FDA does not have the authority to require foreign establishments to allow the agency to inspect their facilities. However, FDA has the authority to prevent the importation of products manufactured at establishments that refuse to allow an FDA inspection. Because no medical products are absolutely safe—there is always some risk of an adverse event—FDA continues to assess products’ risks and benefits after the products are on the market by using multiple strategies. One such strategy is to collect and analyze adverse event reports related to the use of medical products and monitor them to identify potential safety issues associated with the use of a specific medical product. FDA receives adverse event reports from various sources, including medical product manufacturers, physicians, and the public. FDA requires medical product manufacturers and others to submit reports of adverse events associated with the use of a medical product to FDA at certain frequencies depending on the seriousness of the adverse event and the amount of time the product has been on the market. Physicians and the public may voluntarily submit reports of adverse events to FDA at any time. The agency’s review of these reports helps to identify, among other things, unexpected adverse events, product quality problems, and product use errors related to marketed medical products. These reviews provide information that may lead FDA to require the product’s sponsor to conduct a safety study, make changes to product labeling, or recall a product from the market. FDA oversees the advertising and promotion of prescription drugs, biologics, and some devices to ensure that information disseminated about medical products is not false or misleading. FDA regulations also require that product promotions include a balanced disclosure of side effects, contraindications, and warnings. In addition, advertising and promotions may not recommend or suggest any use of a product that is not included in the product’s approved labeling. FDA regulates the content of advertising and promotions regardless of whether they are directed toward consumers or medical professionals. FDA regulations require manufacturers to submit to the agency all final advertising and promotional materials for drugs and biologics at the time the materials are first disseminated to the public. In contrast, FDA does not require manufacturers to submit advertising and promotional materials for devices at the time of their initial dissemination. Companies may also voluntarily submit draft advertising and promotional materials to FDA prior to their public release in order to obtain advisory comments from the agency. Although FDA is not required to review all materials submitted, reviewing final and draft advertising and promotional materials is the agency’s primary mechanism for ensuring that information disseminated about drug and biologic products is not false or misleading. To supplement its examination of submitted materials, FDA staff also monitor the content of disseminated advertising and promotional materials, for example, by attending medical conferences, reviewing company Web sites, and following up on complaints received. Funding and staffing for FDA’s medical product programs have increased mostly as a result of user fee funding, which is primarily directed toward the agency’s review of new medical products. FDA is required to apply a certain amount of its fiscal year appropriations to support user fee activities, and agency officials said that this requirement limits the resources available for other medical product program activities that are not supported by user fee funding. In addition to their concerns about the sufficiency of their resources, FDA officials are concerned about the agency’s ability to hire and retain staff in certain scientific occupations. Funding for FDA’s medical product programs increased between fiscal year 1999 and fiscal year 2008, mostly due to increases in user fee funding. Medical product program funding increased 112 percent overall, from about $562 million in fiscal year 1999 to about $1.2 billion in fiscal year 2008. (See fig. 2.) This funding increase was greater than the GDP rate of inflation across this time period—25 percent. Over half of the increase in medical product program funding was due to growth in user fee funding, which grew four times as fast as fiscal year appropriations during this 10-year period. Between fiscal years 1999 and 2008, user fee funding increased 268 percent from about $120 million to about $443 million, while fiscal year appropriations increased 69 percent from about $441 million to about $746 million. Over three-quarters of the increase in user fee funding over this period supported the drugs program, with the remaining portion supporting the biologics and devices programs. Appendix I provides additional information on funding and staffing resources for FDA’s medical product programs. Between fiscal years 1999 and 2008, total funding for FDA’s medical product programs—including fiscal year appropriations and user fee funding—grew 112 percent. This rate of growth was higher than the rates of growth in total funding for the rest of FDA (86 percent), as well as total funding for HHS (98 percent) and the federal government (87 percent). The high rate of growth in total funding for FDA’s medical product programs was due to large increases in FDA’s user fee funding. Fiscal year appropriations for FDA’s medical product programs grew at a slower rate than fiscal year appropriations for other FDA programs between fiscal years 1999 and 2008, as shown in table 1. Fiscal year appropriations for FDA’s medical product programs also grew at a slower rate (69 percent) than discretionary funding for HHS (74 percent) and the federal government (103 percent). PDUFA and MDUFMA require the agency to apply all user fee funding, as well as a specified amount of fiscal year appropriations, to support user fee activities that are related to the agency’s process for reviewing applications for new drugs, new biologics, and certain new devices. Taking this requirement into account, we found that total funding for the medical product programs’ user fee activities increased eight times faster than funding for the programs’ other activities between fiscal years 1999 and 2008. Specifically, funding for user fee activities increased 207 percent over the 10-year period while total funding for the programs’ other activities increased 25 percent—the same rate as inflation over this period as measured by the GDP price index. As funding for user fee activities grew faster between fiscal year 1999 and 2008 than funding for other program activities not funded with user fees, a declining share of fiscal year appropriations was available to other program activities. In fiscal year 1999, the medical product programs allocated 48 percent of their total $562 million funding—including 33 percent of their fiscal year appropriations—to user fee activities. In fiscal year 2008, these programs allocated 69 percent of their total $1.2 billion funding—including 51 percent of their fiscal year appropriations—to user fee activities. In fiscal year 2008, the medical product programs allocated 31 percent of their total funding to other program activities not funded by user fees. (See fig. 3.) Although total funding increased, FDA officials reported that the decline in the portion of funding available to activities not funded by user fees has seriously limited the agency’s ability to fulfill its oversight responsibilities in some areas. FDA officials noted a disproportionate growth in funding available for the agency’s user fee activities compared with other agency activities not funded with user fees, such as the agency’s oversight of transfusion-related blood products, human tissues, device compliance and enforcement, and radiological health, as well as its work in reviewing ANDAs, examining drug-related advertising materials, and conducting inspections of establishments manufacturing approved drugs. To supplement our analysis of trends in FDA resources from fiscal years 1999 through 2008, we analyzed how FDA’s medical product programs allocated funding to center and field activities from fiscal years 2004 through 2008. We found that each of the medical product programs allocated most of their annual funding to activities conducted by the centers (CDER, CBER, and CDRH). The programs also provided some funding for field activities conducted by ORA. We found that funding for the medical product programs’ center activities grew three times as fast as funding for the programs’ field activities. We also noted that funding for field activities increased at about the same rate as the GDP inflation rate. (See app. II for additional information on trends in center and field funding and staffing resources for the medical product programs.) Staffing resources for FDA’s medical product programs increased between fiscal year 1999 and fiscal year 2008. The number of FTEs supporting FDA’s medical product programs increased 14 percent from 4,925 FTEs in fiscal year 1999 to 5,626 FTEs in fiscal year 2008. This increase was due solely to a growth in the number of FTEs funded by user fees—the number of FTEs funded by fiscal year appropriations declined. Specifically, the number of medical product program FTEs funded by user fees increased 113 percent—from 856 FTEs in fiscal year 1999 to 1,825 FTEs in fiscal year 2008—while FTEs funded by fiscal year appropriations declined 7 percent, or from 4,069 FTEs in fiscal year 1999 to 3,802 FTEs in fiscal year 2008. FDA officials told us that they had to actively reduce the number of staff by offering buyouts to employees to leave the agency between fiscal years 2004 and 2006 because the agency did not receive enough fiscal year appropriations in these years to maintain staffing levels. According to FDA officials, FTE costs—salary and benefit costs—grew at a faster rate than fiscal year appropriations during this period. Figure 4 displays the number of FTEs from fiscal year appropriations and user fees for each year, fiscal years 1999 through 2008. While our analysis of FDA data shows that the number of medical product program FTEs increased between fiscal year 1999 and 2008, FTEs do not include contractors and therefore provide a partial measure of total staffing resources. FDA could not provide data showing the total number of contractors it used or the total amount of funding it spent on contractors to support its medical product programs over this period. As a result, we could not fully assess the medical product programs’ staffing resources. FDA officials estimated that the agency used an increasing number of contractors to fulfill its medical product responsibilities between fiscal years 1999 and 2008. However, agency officials were unable to provide us with data to corroborate this estimate. According to FDA officials, the decline in the number of FTEs funded by FDA’s fiscal year appropriations limited the agency’s ability to fulfill its medical product oversight responsibilities. FDA officials noted that they do not have enough staff to adequately perform duties that do not receive user fee funding, such as the agency’s review of ANDAs, oversight of product advertising and promotion, and inspections of establishments manufacturing marketed products. As a result, FDA officials noted that the agency’s work in these areas is increasingly backlogged. In addition to their concerns about the adequacy of the agency’s fiscal year appropriations, FDA officials are also concerned about the agency’s ability to hire staff, particularly those in certain scientific occupations. For example, FDA officials noted that the agency is facing challenges hiring biologists, chemists, computer programmers, consumer safety officers, engineers, epidemiologists, mathematical statisticians, medical officers, and pharmacologists, among other occupations. FDA officials noted that the lack of sufficient numbers of staff and extended vacancies in specific occupations resulted in higher workloads and longer hours for current staff, as well as postponed or reduced work in some areas. FDA officials also noted concerns about the agency’s ability to retain staff, particularly those in certain scientific occupations. FDA officials said that a high percentage of staff from the medical product centers and ORA leave their positions—including those who move within FDA, leave the agency, and retire. Specifically, FDA data show that between 2000 and 2007, the average annual percent of staff who left their positions at CDER, CBER, and CDRH ranged from 11 to 13 percent, and at ORA headquarters and regional offices ranged from 6 to 23 percent. However, a portion of these staff stayed within FDA and HHS. FDA officials told us that the loss of any staff from their centers presents challenges as it takes time for the centers to hire and train new staff. For example, FDA officials noted that it takes about 2 years to effectively train new staff who review applications for new medical products. New laws and a growing workload increased FDA’s medical product oversight responsibilities. FDA did not fulfill its oversight responsibilities between fiscal years 2004 and 2008 in some areas, which agency officials attributed to resource constraints. Laws enacted since 1999 added new requirements that expanded FDA’s medical product oversight responsibilities. On the basis of our review, we found 11 laws that specifically added to FDA’s medical product oversight responsibilities. These 11 laws were enacted between 2002 and 2007. (See fig. 5.) These 11 laws added many additional requirements and authorities to FDA, increasing the agency’s oversight responsibilities ranging from premarket review of medical products to the agency’s oversight of the safety of marketed medical products. These additional oversight responsibilities included an expansion in FDA’s authority to regulate devices, an increase in the amount of information that the agency needs to review before deciding whether to approve new drugs and biologics, and greater authority to monitor the safety of approved products. To implement these new requirements and authorities, FDA, for example, needed to issue new guidance for industry and new operating procedures for staff, and established new committees that the agency needed to consult with to fulfill its oversight responsibilities. One of the many new oversight responsibilities that FDA was charged with was added by MDUFMA. In 2002, MDUFMA instituted a regulatory oversight function for reprocessed single-use devices. MDUFMA required manufacturers of certain devices to submit additional information to the agency validating that reprocessed single-use devices are substantially equivalent to current or previously marketed single-use devices. The law also created a new application for the approval of reprocessed high-risk devices. As a result of these new authorities, FDA created new guidance documents and conducted presentations with industry and healthcare professionals related to the agency’s oversight of these products. According to agency officials, the implementation of this expanded authority resulted in a significant increase in FDA’s workload, particularly in 2002 when FDA officials estimated that about 17 FTEs were dedicated to implementing this authority and developing guidance documents. Another law, the Pediatric Research Equity Act of 2003 (PREA), increased the amount of information that FDA must review to approve a new drug or new biologic. FDA became responsible for reviewing more materials to assess the products’ safety and effectiveness for children, including appropriate information to include on product labeling. Specifically, PREA required sponsors to submit a pediatric assessment containing additional information about the pediatric use of a drug or biologic at the time they submit an application or supplement. As a result of the reviews of these required pediatric assessments, FDA issued 86 PREA-related labeling changes for drugs and biologics between December 2003 and December 2008. A more recent example of a law increasing FDA’s medical product responsibilities is the Food and Drug Administration Amendments Act of 2007 (FDAAA). FDAAA increased FDA’s postmarket oversight responsibilities for medical products by giving FDA authority to require sponsors to conduct studies or clinical trials for approved drugs in cases where FDA has identified new safety concerns. To require such a study, FDA officials said that they document their rationale in a legally enforceable contract with a sponsor. These contracts may outline specific elements of the study design. FDA officials stated that the process of developing such contracts results in additional work for the agency. From the enactment of FDAAA in September 2007 through January 2009, FDA required drug sponsors to conduct 45 postmarket studies for NDAs and biologics sponsors to conduct 15 postmarket studies for BLAs, for drugs and biologics approved before and after the implementation of FDAAA. FDA also faced a growing workload and was responsible for overseeing increasing numbers of marketed products and establishments. FDA’s medical product workload grew between fiscal years 1999 and 2008 in part due to the receipt of an increasing number of applications and application supplements. The number of drug, biologic, and device application materials submitted to FDA grew 30 percent over this period, from 23,079 in fiscal year 1999 to 30,060 in fiscal year 2008. In particular, the number of application supplements grew 48 percent (from 13,694 application supplements in fiscal year 1999 to 20,329 application supplements in fiscal year 2008). The number of medical product applications also increased during this time period by 8 percent, or from 8,313 applications to 8,943 applications. At the same time, the number of applications resubmitted for medical product approval decreased 26 percent from 1,072 to 788 (see fig. 6). In addition to receiving an increasing number of applications and application supplements, FDA’s workload also grew due to an increase in other demands placed on the agency. For example, FDA received 797,889 more reports of adverse events related to medical products in fiscal year 2008 than in fiscal year 1999, an increase of 228 percent. FDA also received 40,193 more drug- and biologic-related advertising and promotional materials to examine (an increase of 115 percent), and 885 more meeting requests from sponsors regarding drug and biologic products in development during this time period (an increase of 56 percent). The complexity of products subject to FDA oversight has also grown, thus increasing the agency’s workload. FDA officials, as well as FDA’s Science Board, reported that rapid advances in science and technology, including the fields of genomics and nanotechnology, have increased the complexity of the medical products submitted to FDA for premarket approval. FDA officials told us that the agency seeks and provides training for its reviewers so they can more effectively review the safety and effectiveness of these increasingly complex products. However, agency officials said that this training results in less time available for staff to perform their routine duties. In addition, FDA officials also increasingly seek the advice of scientific experts from outside the agency, including advisory committee members, to assist in the review of applications for new drugs and new biologics. Similarly, seeking the advice of experts requires additional staff time to obtain and weigh these perspectives. In addition to facing a growing workload, the total number of medical products and establishments FDA oversees also increased between fiscal years 1999 and 2008. FDA is responsible for monitoring the safety of marketed medical products, and as the number of these products and manufacturing establishments has grown, so have the agency’s oversight responsibilities. The number of medical products approved or cleared for marketing has grown 55 percent, or by 41,203 medical products, during this time period. In addition, the total number of establishments registered to produce medical products marketed for sale in the United States—a proxy for the number of establishments subject to FDA oversight and inspection—grew over this time period, due to increases in the number of foreign establishments. However, from fiscal years 1999 to 2008, FDA saw a decrease—2 percent or 311 establishments—in the number of domestic establishments registered to produce medical products. Over the same time period, the number of foreign establishments registered to produce medical products increased by 23 percent or 1,921 establishments. See table 2 for trends in domestic and foreign establishments registered to produce medical products. FDA officials told us that resource constraints hindered the agency’s ability to fulfill all of its medical product oversight responsibilities between fiscal years 2004 and 2008, but the agency also lacked information to manage some of these oversight responsibilities and estimate current and future resource needs. For the two key areas we reviewed where statutory requirements and performance goals set expectations for the agency’s work during this period—review of applications for generic drugs, new drugs, and new biologics, and medical product inspections— FDA did not meet all of its medical product oversight responsibilities. In the other two key areas we reviewed—examination of advertising and promotional materials and review of adverse event reports—we found that while FDA faced an increasing workload, it could not always provide data on the work it performed to fulfill these responsibilities. FDA did not meet all of its medical product oversight responsibilities where requirements and performance goals set expectations for the agency’s work from fiscal years 2004 through 2008. For example, FDA did not meet the requirement to complete its first review of ANDAs within 180 days of receipt during this period. We found that the percent of ANDAs that FDA reviewed within this 180 day requirement declined from 87 percent in fiscal year 2004 to 32 percent in fiscal year 2008. FDA received an increasing number of ANDAs during this time period, and agency officials explained that they were unable to review all applications submitted within the 180 day requirement because they did not have sufficient resources to conduct these reviews. As a result, an increasing number of ANDAs were pending review, creating a backlog. While FDA met most of its PDUFA performance goals related to the speed at which it reviewed NDAs and BLAs and related application supplements, the agency did not meet most PDUFA performance goals related to the speed at which it scheduled and held meetings with sponsors and responded to sponsor requests for information between fiscal years 2004 and 2008. FDA officials explained that they were unable to meet all of these performance goals due to inadequate resources. FDA officials explained that they placed a higher priority on reviewing applications and therefore had fewer resources to schedule and hold meetings or respond to sponsors’ requests for information. FDA also did not meet all of its inspection requirements and requested additional funding to begin conducting more inspections. FDA did not conduct inspections every 2 years as required for two of three types of establishments we reviewed. FDA officials estimated that the agency, on average, conducts inspections of domestic drug manufacturers every 3 years, domestic device manufacturers every 3 or 5 years, and domestic blood banks every 2 years. FDA officials estimated that the agency conducts inspections less frequently for other types of establishments that do not have required time frames for the frequency of inspections— domestic human tissue banks, foreign drug manufacturers, and foreign device manufacturers. (See table 3.) In fiscal year 2008, FDA requested and received additional funding to strengthen field operations and conduct more domestic and foreign inspections of medical product establishments. FDA faced an increasing workload in the other two areas we reviewed— review of adverse event reports and examination of advertising and promotional materials. Agency officials said they lacked sufficient resources in these areas. Similar to what we reported in 1989, we found that FDA lacks information to manage these responsibilities and estimate current and future resource needs. Although adverse event monitoring is a key mechanism for FDA to identify postmarket safety risks related to the use of marketed medical products, agency officials told us that they receive substantially more drug-, biologic-, and device-related adverse event reports than staff can review. Between fiscal years 2004 and 2008, FDA received an increasing number of adverse event reports for medical products, from 635,035 reports in fiscal year 2004 to 1,147,442 reports in fiscal year 2008. However, FDA officials could not provide data showing how many adverse event reports staff review. FDA officials told us that they place the highest priority on reviewing reports of serious adverse events, such as those involving death or severe injury, and unexpected adverse events—those not noted on approved product labeling. Yet, FDA officials were unable to provide data to corroborate their reviews of these reports of serious and unexpected events. In addition, while FDA receives relatively few promotional materials for biologics and devices, the agency receives substantially more drug-related promotional materials than staff can review, according to agency officials. Between fiscal years 2004 and 2008, FDA received a steadily increasing number of final promotional materials—from 45,394 in fiscal year 2004 to 70,509 in fiscal year 2008. Again, FDA could not provide data showing how many drug-related advertising and promotional materials staff review. Although FDA officials told us that they place a high priority on reviewing materials that have the greatest potential to affect public health, they were unable to provide data to corroborate their reviews of these materials. FDA officials have told us that collecting data on the work staff performed would be time-consuming and detract from resources needed to devote to conducting these reviews. While FDA officials noted the agency’s inability to fulfill all of its responsibilities due to resource constraints, FDA does not have the data to develop a complete and reliable estimate of the resources it needs to conduct all of its responsibilities. Specifically, we found that FDA lacked information about its current resources, workload, and performance in some areas, such as with the review of adverse event reports and promotional materials. This basic management information is critical to the development of a complete and reliable resource estimate. FDA officials also told us that the funding amounts requested for FDA and provided by Congress during the past 2 years will permit the agency to respond to its most urgent needs and priorities, although officials also noted that they did not receive enough resources to meet some statutory requirements. For example, agency officials noted that they were unable to inspect certain manufacturing establishments at prescribed intervals due to resource constraints. Furthermore, FDA officials also noted that the agency continues to face significant challenges fulfilling its mission. For more information on the trends in FDA’s workload and resources for the four key areas that we reviewed, see appendix III for FDA’s review of generic drug, new drug, and new biologic applications, appendix IV for inspections of medical product research activities and manufacturing establishments, appendix V for the review of adverse event reports, and appendix VI for the examination of advertising and promotional materials. The growth in the complexity and number of new medical products and the establishments manufacturing them, increasing globalization, and added statutory requirements and responsibilities have translated into mounting and competing demands for FDA’s resources. Concerns regarding the adequacy of these resources are not new, but as demands on the agency have soared in recent years, these concerns have intensified. Earlier this year, we included FDA’s oversight of medical products in our High-Risk Series. Our current examination of FDA’s resources confirms that the agency’s ability to protect Americans from unsafe and ineffective medical products is compromised. The structure of the agency’s funding— its reliance on user fees to fund certain activities, particularly those related to the review of new products—is a driving force behind which responsibilities FDA does and does not fulfill. The approval of new products has increasingly become the beneficiary of the agency’s budget, without parallel increases in funding for activities designed to ensure the continuing safety of products, once they are on the market. The enactment of FDAAA in 2007 gave FDA the ability to apply user fee funding to more postmarket activities for some types of medical products, providing the agency more flexibility in its use of funding. FDA reports that it cannot do all that is asked of it and our analysis of the agency’s activities confirms this. However, as FDA officials told us, the agency’s requests for resources do not reflect all the resources it needs to fulfill its mission, including meeting its statutory requirements. FDA could not provide data showing its workload and accomplishments in some areas. Furthermore, it lacks other basic management information, such as the size of its contractor workforce. Without this information, FDA does not have data to reliably estimate its resource needs—a problem we reported 20 years ago and which served as the basis of our recommendation that FDA collect such data. Since then we have made similar recommendations that the agency improve its management and tracking of its resources and workload. FDA has disagreed with these recommendations, claiming that it lacks the resources to devote to this data collection and that it would detract from its oversight responsibilities. We acknowledge that FDA is facing significant challenges in fulfilling its responsibilities, but continue to believe that developing such information is an essential component of ultimately enhancing the agency’s ability to adequately fulfill its mission. Without such basic data needed for managing its programs, FDA cannot develop sound and justifiable budget requests that reflect all the work that is vital to fulfilling its mission, including meeting its performance goals and its statutory requirements. It is also difficult for others to independently verify the extent to which FDA receives sufficient resources and whether the agency is appropriately utilizing and prioritizing the resources it receives. We recommend that the Commissioner of FDA establish a comprehensive and reliable basis to substantiate the agency’s estimates of its current and future resource needs in a manner consistent with the principles contained in our cost estimating and assessment guide. To do so, we recommend that the Commissioner of FDA take the following four actions: 1. Conduct a comprehensive assessment of the agency’s staffing resources, including its contractor workforce. 2. Gather data on the work the agency conducts to fulfill its responsibilities. 3. Assess the extent to which the agency is meeting its responsibilities. 4. Develop an evidence-based estimate of the resources needed to fulfill all of its responsibilities. We provided a draft of this report to HHS for review. HHS provided comments from FDA. In its comments, FDA agreed with our four recommendations and described the steps it would take to implement them. FDA’s comments are reprinted in appendix VII. FDA also provided technical comments, which we incorporated as appropriate. In its comments, FDA acknowledged that we identified some important issues regarding the challenges the agency faces in meeting its medical product responsibilities. It highlighted the President’s requested increase in the agency’s medical product program funding for fiscal year 2010, which it said would support a life-cycle approach to safety, provide for increased inspections, and support the implementation of requirements included in FDAAA. Specifically, regarding our recommendations, FDA said that a comprehensive assessment of its staffing resources would provide useful information and that it will expand its current staffing assessment process to include its contractor workforce. The agency also said it will conduct a complete inventory of all regulatory work products by FDA center and that it would identify and implement measures to determine how effectively the agency is meeting its responsibilities. Finally, FDA said that it plans to link these measures to its budget and funding allocation. FDA said that this approach will inform the agency about how well it is allocating its resources and help identify what additional resources it needs to fulfill its responsibilities. We believe that the agency’s completion of the activities described, as well as other necessary and related actions to implement our recommendations, should assist FDA in developing a comprehensive and reliable basis for substantiating the agency’s resource needs and help it better manage its medical product programs. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the Commissioner of FDA and appropriate congressional committees. The report also will be available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or crossem@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix VIII. Funding resources for the Food and Drug Administration’s (FDA) medical product programs increased 112 percent between fiscal years 1999 and 2008. Of the medical product programs drugs program funding increased 145 percent, from $278.3 million in fiscal year 1999 to $680.9 million in fiscal year 2008; biologics program funding increased 88 percent, from $124.4 million in fiscal year 1999 to $233.5 million in fiscal year 2008; and devices program funding increased 73 percent, from $159.0 million in fiscal year 1999 to $275.3 million in fiscal year 2008. Table 4 displays funding resources for FDA programs for fiscal years 1999 through 2008. Staffing resources supporting FDA’s medical product programs—as measured by the number of full-time equivalent (FTE) staff—varied from year to year, and increased 14 percent between fiscal year 1999 and fiscal year 2008. Specifically, drugs program FTEs increased 22 percent from 2,456 FTEs in fiscal year 1999 to 2,996 FTEs in fiscal year 2008; biologics program FTEs increased 8 percent from 989 FTEs in fiscal year 1999 to 1,066 in fiscal year 2008; and devices program FTEs increased 6 percent from 1,480 FTEs in fiscal year 1999 to 1,564 FTEs in fiscal year 2008. Table 5 displays staffing resources for FDA programs from fiscal years 1999 through 2008. Between fiscal years 2004 and 2008, the drugs, biologics, and devices programs allocated most of their funding and staffing to center activities, leaving a smaller share of resources for field activities. Funding for center activities grew faster than funding for field activities, which increased at nearly the same rate as inflation, as measured by the gross domestic product (GDP) price index. During the same period, staffing resources for center activities increased while staffing resources for field activities decreased. Funding for center activities grew more than three times as fast as funding for field activities between fiscal years 2004 and 2008. Specifically, center funding for all medical product programs combined grew from $675 million to $995 million over this period, an increase of 47 percent, while field funding for all medical programs increased from $173 million to $195 million, an increase of 13 percent. (See fig. 7.) While increases in total center funding outpaced the GDP inflation rate of 12 percent during this period, the rate of increase in total field funding remained close to the GDP inflation rate. Drugs program funding for center activities conducted by the Center for Drug Evaluation and Research (CDER) increased 57 percent from about $373 million in fiscal year 2004 to about $588 million in fiscal year 2008, while funding for field activities conducted by the Office of Regulatory Affairs (ORA) rose 8 percent from about $86 million to about $93 million over this period. The increase in field funding for this program was less than the rate of GDP inflation (12 percent) over this period. Biologics program funding for center activities conducted by the Center for Biologics Evaluation and Research (CBER) increased 45 percent from about $140 million in fiscal year 2004 to about $202 million in fiscal year 2008, while funding for biologics field activities conducted by ORA increased 15 percent over this period, from about $27 million to about $31 million. Devices program funding for center activities conducted by the Center for Devices and Radiological Health (CDRH) increased 26 percent from about $162 million in fiscal year 2004 to about $205 million in fiscal years 2008, while funding for field activities conducted by ORA increased 18 percent, from about $60 million to about $70 million. Over two-thirds of each of the medical product centers’ funding supported their user fee activities in fiscal year 2008. Specifically, CDER, CBER and CDRH each allocated about 78 percent of their centers’ total funding—including an average of 61 percent of the centers’ total fiscal year appropriations—to user fee activities in fiscal year 2008, leaving 22 percent of funding to support the centers’ other activities. In contrast, 23 percent of the medical product programs’ total field funding supported user fee activities, with 77 percent of field funding supporting other activities not funded with user fees. Table 6 displays how the medical product programs allocated funding resources to specific center and field activities. The number of full-time equivalent (FTE) staff supporting center activities grew 8 percent from 4,048 FTEs in fiscal year 2004 to 4,384 in fiscal year 2008, while the number of FTEs supporting field activities conducted by ORA decreased 15 percent from 1,454 FTEs in fiscal year 2004 to 1,243 FTEs in fiscal year 2008. (See fig. 8.) Because counts of FTEs do not include contractors, these data do not fully represent FDA’s staffing resources for these activities. Drugs program staffing resources for CDER activities grew 9 percent from 2,190 FTEs in fiscal year 2004 to 2,396 FTEs in fiscal year 2008, while staffing resources for drugs field activities declined 21 percent from 759 FTEs in fiscal year 2004 to 600 FTEs in fiscal year 2008. Biologics program staffing resources for CBER activities grew 8 percent from 797 FTEs to 858 FTEs, while FTEs supporting biologics field activities declined 13 percent from 241 FTEs to 209 FTEs. Devices program staffing resources for CDRH activities grew 7 percent from 1,061 FTEs to 1,130 FTEs, while staffing resources for devices field activities declined 4 percent from 454 FTEs to 434 FTEs. Table 7 shows how FDA’s medical product programs allocated FTE resources to various center and field activities. The Food and Drug Administration (FDA) faced an increasing workload related to the process for reviewing generic drug, new drug, and new biologic applications between fiscal year 2004 and fiscal year 2008. For example, FDA received 47 percent more applications for generic drugs in fiscal year 2008 than in fiscal year 2004. Even though FDA funding for the review of these applications grew 53 percent over this time period, agency officials said that resource constraints precluded them from reviewing all applications submitted, resulting in a growing number of applications pending review. FDA reviewed an increasing number of abbreviated new drug applications (ANDA) for generic drugs between fiscal years 2004 and 2008. However, FDA received a greater number of applications each year than it was able to review. The number of original ANDAs received for review increased by 47 percent—from 563 in fiscal year 2004 to 830 in fiscal year 2008. During this time period, FDA reviewed an increasing number of ANDAs each year. In fiscal year 2004, FDA reviewed 1,357 ANDAs and in fiscal year 2008 the agency reviewed 1,933 ANDAs—an increase of 42 percent. While the number of ANDAs the agency reviewed each year increased, FDA was not able to review them all. As a result, the number of applications pending review increased 123 percent over the period. (See table 8.) FDA officials told us that they were unable to review all ANDAs because they did not have enough resources to conduct these reviews. Between fiscal year 2004 and fiscal year 2008, FDA conducted an increased amount of work related to the review of new drug and new biologic applications. In particular, FDA was increasingly involved in the process of new drug and new biologic development, which typically occurs years before sponsors submit a new drug application (NDA) or biologics license application (BLA) to FDA for approval. FDA reported that sponsors’ early consultation with the agency generally results in improvements in the safety and effectiveness of the clinical trials. In addition, FDA indicated that the agency’s increased involvement generally improves the quality of information submitted in an application for marketing approval and increases the likelihood that the resulting application will gain faster approval. The number of active investigational new drugs (IND)—representing new drugs and new biologics in development—grew from 12,523 in fiscal year 2004 to 15,020 in fiscal year 2008. To guide the development of these new products, FDA issued an increasing number of written guidance documents to sponsors between fiscal year 2004 and fiscal year 2008. For example, FDA issued 135 responses to clinical holds in fiscal year 2004 and 213 such responses in fiscal year 2008. In addition, while the number of meetings FDA conducted with sponsors regarding new drug development varied from year to year, between fiscal year 2004 and fiscal year 2008 FDA scheduled over 10,000 meetings with sponsors, with between 1,900 and 2,300 such meetings each year. (See table 9.) FDA officials stated that drafting written responses and preparing for and documenting the results of meetings with sponsors requires a substantial amount of staff time. In particular, FDA noted that each meeting typically requires the involvement of at least 15 FDA staff and can require between 120 to 540 hours of staff time. Although FDA was increasingly involved in the process of new drug and new biologic development between fiscal year 2004 and fiscal year 2008, the agency’s review of NDAs and BLAs decreased slightly over the time period, following trends in the number of applications the agency received. As shown in table 9, the total number of original and resubmitted NDAs and BLAs FDA received decreased from 214 applications in fiscal year 2004 to 197 applications in fiscal year 2008. FDA also reviewed a decreasing number of NDAs and BLAs—in fiscal year 2004 FDA reviewed 206 original and resubmitted NDAs and BLAs and in fiscal year 2008 FDA reviewed 161 such applications. FDA also reviewed between about 3,700 and 4,000 efficacy, labeling, and manufacturing NDA and BLA supplements each year during this period. FDA has many performance goals related to its process for reviewing new drug applications. According to FDA officials, the agency places a higher priority on the speed with which it reviews applications for new drugs and biologics, compared to the speed with which the agency responds to sponsor requests for information and scheduling and holding meetings with sponsors. As a result of this prioritization, FDA focused its resources on its review of applications—and we found FDA generally met its performance goals in this area. However, agency officials noted that the agency did not have sufficient resources to meet performance goals related to responding to sponsor requests for information and scheduling and holding meetings. Between fiscal year 2004 and fiscal year 2008, funding for FDA’s review of ANDAs—which is provided solely through FDA’s fiscal year appropriations—increased 53 percent from about $53 million in fiscal year 2004 to about $82 million in fiscal year 2008. Over the same period, funding resources for FDA’s process for reviewing NDAs and BLAs, an activity that receives both user fee funding and fiscal year appropriations, increased 58 percent. Specifically, funding increased from $437 million in fiscal year 2004 to $691 million in fiscal year 2008. During the same period, the number of full-time equivalent (FTE) staff supporting the agency’s review of ANDAs decreased 12 percent from 427 FTEs in fiscal year 2004 to 376 FTEs in fiscal year 2008. In contrast, the number of FTEs supporting the agency’s review of new drug and new biologic applications increased from 2,561 FTEs in fiscal year 2004 to 2,780 FTEs in fiscal year 2008. This increase in FTEs was solely due to an increase in the number of FTEs funded by user fees. Because counts of FTEs do not include contractors, these data do not fully represent FDA’s staffing resources for these activities. Between fiscal years 2004 and 2008, the number of medical product inspections the Food and Drug Administration (FDA) conducted decreased 17 percent—primarily due to a 19 percent decrease in the number of domestic inspections. Although the total number of inspections decreased, funding for inspections grew 16 percent overall, and the rate of funding increases for drugs and biologics inspections did not keep pace with inflation, as measured by the gross domestic product (GDP) price index. The agency conducted an increasing number of foreign inspections, which on average cost more than twice as much as each domestic inspection, and may explain why increased inspection funding supported a fewer number of total inspections. The total number of inspections FDA conducted for its medical product programs decreased from 7,589 inspections in fiscal year 2004 to 6,306 inspections in fiscal year 2008, a decline of 1,283 inspections or 17 percent. The total number of inspections conducted for each program decreased over the time period. (See fig. 9.) Between fiscal years 2004 and 2008, FDA decreased the number of domestic medical product program inspections conducted each year. FDA conducted 6,849 domestic inspections in fiscal year 2004 and 5,543 domestic inspections in fiscal year 2008—a decline of 19 percent or 1,306 inspections over the 5-year time period. FDA reduced the number of domestic inspections it conducted for each of the medical product programs between fiscal years 2004 and 2008. For the drugs program, FDA conducted 2,241 domestic inspections in fiscal year 2004 and 1,772 such inspections in fiscal year 2008—a decrease of 469 inspections or 21 percent. For the biologics program, FDA conducted 2,009 domestic inspections in fiscal year 2004 and 1,678 domestic inspections in fiscal year 2008, a decrease of 331 inspections or 16 percent. For the devices program, FDA conducted 2,599 domestic inspections in fiscal year 2004 and 2,093 domestic inspections in fiscal year 2008, a decline of 506 inspections or 19 percent. FDA conducted fewer domestic medical product inspections overall, although the agency increased the number of certain types of domestic inspections. For example, within the biologics program, FDA increased the number of domestic inspections of human cellular, tissue, and gene therapy products, and vaccines and allergenic products between fiscal years 2004 and 2008. In addition, FDA increased the number of domestic postmarket assurance device inspections it conducted over the 5 year period. (See table 10.) While the number of domestic inspections declined for medical product programs overall between fiscal year 2004 and fiscal year 2008, FDA increased the number of foreign inspections it conducted for the drugs and biologics programs. The total number of foreign inspections fluctuated from year to year, and in fiscal year 2008, FDA conducted a total of 763 foreign inspections—23 more than it did in 2004. For the drugs program, FDA conducted 374 foreign inspections in fiscal year 2004 and 452 such inspections in fiscal year 2008—an increase of 78 inspections. For the biologics program, FDA conducted 17 foreign inspections in fiscal year 2004 and 50 such inspections in fiscal year 2008—an increase of 33 inspections. For the devices program, FDA conducted 349 foreign inspections in fiscal year 2004 and 261 such inspections in fiscal year 2008—a decrease of 88 inspections. Despite increases in the total number of foreign inspections conducted over this time period, they constituted a small share—12 percent—of the total number of medical product program inspections in fiscal year 2008. In addition, FDA is only able to reach a small share of the total number of foreign establishments producing medical products for the U.S. market. In fiscal year 2008, FDA conducted inspections at 749 foreign establishments, which represented about 7 percent of the 10,158 total foreign medical product establishments registered with the agency that year. FDA conducted 17 percent fewer medical product inspections in fiscal year 2008 than it did in fiscal year 2004, although Office of Regulatory Affairs (ORA) funding for these inspections increased 16 percent during this period—from about $101 million to about $117 million. While the total number of medical product inspections FDA conducted decreased, the agency conducted more foreign inspections over this time period. FDA estimates that, on average, the cost of a foreign inspection is more than twice the cost of a domestic inspection. The agency’s increase in foreign inspections may explain why increased inspection funding supported fewer total inspections. Although funding for inspections was greater in fiscal year 2008 than in fiscal year 2004, it did not increase in each of these 5 years for each medical product program. Funding for the drugs and biologics program inspections remained relatively constant between fiscal years 2004 and 2005, decreased in fiscal year 2006, and increased in fiscal years 2007 and 2008. In fiscal year 2008, funding for drugs program inspections was 1 percent greater than it was in fiscal year 2004, and funding for biologics program inspections was 8 percent greater than it was in fiscal year 2004. These rates of increase in funding were substantially lower than the GDP rate of inflation between fiscal years 2004 and 2008 of 12 percent. For the devices program, funding remained relatively constant between fiscal years 2004 and 2005, increased in fiscal years 2006 and 2007, and remained relatively constant between fiscal years 2007 and 2008. Over this period, funding for devices program inspections increased 46 percent. (See fig. 10.) Although ORA funding for inspection activities increased between fiscal year 2004 and fiscal year 2008, the number of ORA full-time equivalent (FTE) staff devoted to medical product inspections declined 19 percent during this time period, from 844 FTEs in fiscal year 2004 to 684 FTEs in fiscal year 2008. Each of the medical product programs experienced a decline in FTEs conducting inspections during this time period. Compared to fiscal year 2004 FTE levels, in fiscal year 2008 there were 114 fewer FTEs devoted to drug inspections (a decline of 27 percent), 38 fewer FTEs devoted to biologics inspections (a decline of 19 percent), and 8 fewer FTEs devoted to device inspections (a decline of 4 percent). Most of the decreases in FTEs occurred between fiscal year 2004 and fiscal year 2006. (See fig. 11.) Although contractors do not perform establishment inspections, they may conduct activities that facilitate these inspections. Because counts of FTEs do not include contractors, these data do not fully represent FDA’s staffing resources for these activities. From fiscal years 2004 to 2008, the Food and Drug Administration (FDA) received an increasing number of adverse event reports for marketed medical products—substantially more reports than staff could review, according to FDA officials. While the total number of adverse event reports FDA received increased 81 percent over this time period, funding increased 154 percent and staffing resources increased 100 percent. Although FDA officials told us they received more adverse event reports than staff could review, the agency could not provide data showing the number of adverse event reports staff reviewed during this time period. From fiscal years 2004 to 2008, FDA received an increasing number of adverse event reports for marketed medical products. During this time period the number of drug-related adverse event reports FDA received increased 23 percent, from 426,016 reports in fiscal year 2004 to 522,871 reports in fiscal year 2008. An even bigger increase occurred in the receipt of biologic adverse event reports, which increased 86 percent, from 19,569 reports in fiscal year 2004 to 36,410 reports in fiscal year 2008. FDA saw the highest growth—210 percent—in device-related adverse event reports, with 189,450 reports received in fiscal year 2004 and 588,161 reports received in fiscal year 2008. As the number of adverse event reports for drugs, biologics, and devices grew between fiscal years 2004 and 2008, the number of reports that FDA considers to be serious increased 72 percent. Although FDA officials told us that they place the highest priority in reviewing serious adverse event reports, agency officials reported that they receive substantially more adverse event reports than staff can review. However, FDA could not provide data showing how many adverse event reports staff have reviewed. According to agency officials, the drug, biologic, and device adverse event reporting systems used by FDA do not allow the agency to accurately determine if an individual adverse event report has been reviewed by staff. FDA’s financial and staffing resources for the review of adverse event reports associated with the use of marketed medical products have grown from fiscal years 2004 to 2008. Overall, funding for adverse event reviews has increased 154 percent during this time period from about $31 million in fiscal year 2004 to about $78 million in fiscal year 2008. FDA experienced the greatest growth in financial resources for the review of drug-related adverse event reports with a 215 percent increase or from about $19 million in fiscal year 2004 to about $60 million in fiscal year 2008. Meanwhile, FDA saw the lowest increase in funding—53 percent— for the review of device-related adverse event reports, or from about $10 million in fiscal year 2004 to about $15 million in fiscal year 2008. Funding for adverse event reviews—in total, and for each program—grew at a rate faster than inflation over this time period as measured by the gross domestic product (GDP) price index. See figure 12 for trends in FDA funding for the review of adverse events related to drugs, biologics, and devices. Similar to the increase in funding for reviews related to drugs, biologics, and devices, the number of full-time equivalent (FTE) staff supporting the review of adverse event reports also increased from fiscal years 2004 through 2008. The largest growth in FTEs—248 percent or from 31 FTEs in fiscal year 2004 to 108 FTEs in fiscal year 2008—was for the review of drug-related adverse event reports. Over the same period, the number of FTEs for the review of adverse event reports related to biologics grew 17 percent, from 12 FTEs to 14 FTEs, while the number of FTEs for the review of device-related adverse event reports grew 9 percent, from about 40 FTEs to about 43 FTEs. Because counts of FTEs do not include contractors, these data do not fully represent FDA’s staffing resources for these activities. With the enactment of the Food and Drug Administration Amendments Act of 2007 (FDAAA), FDA was able to apply user fees collected through the Prescription Drug User Fee Act of 1992 (PDUFA), as amended, to support more postmarket safety activities for drugs, such as the review of adverse event reports. FDA attributes about two-thirds of the increase in funding and FTEs between fiscal years 2007 and 2008—142 percent and 40 percent respectively—for the review of drug-related adverse events to user fee funds. The Food and Drug Administration (FDA) faced an increasing workload related to its examination of advertising and promotional materials between fiscal years 2004 and 2008, particularly for drug-related promotions. Such promotions constitute the majority of advertising and promotional materials submitted. While the total number of final drug- related promotional materials FDA received increased 55 percent over the period, agency funding for the examination of these materials increased 167 percent and staff resources increased 26 percent. Although FDA officials noted that the agency did not have sufficient resources to examine all drug-related promotional materials submitted for review, FDA also could not provide information on the number of such materials staff reviewed. During fiscal years 2004 through 2008, FDA received an increasing number of advertising and promotional materials for examination from manufacturers; however, the agency did not track all of the drug- and device-related materials that it received or reviewed during this period. According to FDA officials, the agency was unable to examine all materials promoting drugs, although we found it did examine nearly all such materials for biologics. FDA officials also told us that they review all device-related promotional materials that are submitted. Drugs. FDA received an increasing number of advertising and promotional materials for examination between fiscal year 2004 and fiscal year 2008, but agency officials told us that staff were unable to review all materials submitted. FDA received an increasing number of voluntary draft submissions each year, with 429 submissions in fiscal year 2004 and 634 submissions in fiscal year 2008. In addition to receiving these voluntary draft submissions, FDA received a substantially greater and increasing number of final materials that manufacturers were required to submit. FDA received 45,394 final materials in fiscal year 2004 and 70,509 final materials in fiscal year 2008—an increase of 55 percent over the time period. FDA officials told us that the agency was unable to examine all of the promotional materials for drugs it received between fiscal year 2004 and fiscal year 2008 because it lacked the resources to do so. However, FDA could not provide data on the number of draft or final materials staff examined during this time. Biologics. We found that FDA received and examined an increasing number of draft and final advertising and promotional materials for biologics products between fiscal year 2006—the first year of available data—and fiscal year 2008. Specifically, our review of FDA data showed that the agency examined all 2,929 draft and final promotional materials submitted in fiscal year 2006, all 3,256 materials submitted in fiscal year 2007, and all but 17 of 4,480 materials submitted in fiscal year 2008. Most— over 90 percent—of the total number of materials submitted in each of these years were final promotional materials. Devices. An FDA official told us that the agency received very few promotional materials for devices between fiscal year 2004 and fiscal year 2008—device manufacturers are not required to submit these materials. The official also explained that although all materials received are examined, FDA could not provide data on the number of advertising and promotional materials submitted or examined during this period. Funding for FDA’s oversight of drug advertising and promotion increased 167 percent from about $4 million in fiscal year 2004 to about $10 million in fiscal year 2008. Funding for FDA’s oversight of biologics advertising and promotion also increased from $546,000 in fiscal year 2004 to $925,000 in fiscal year 2008. In contrast, funding for the agency’s oversight of devices advertising and promotion decreased from $590,000 in fiscal year 2004 to $452,000 in fiscal year 2008. The number of full-time equivalent (FTE) staff supporting FDA’s oversight of drug promotions grew 26 percent from 35 FTEs in fiscal year 2004 to 44 FTEs in fiscal year 2008. Over this period, the number of FTEs supporting the agency’s oversight of biologics promotions increased from 4 FTEs to 6 FTEs, while the number of FTEs supporting the agency’s review of devices promotions decreased from 5 FTEs to 4 FTEs. Because counts of FTEs do not include contractors, these data do not fully represent FDA’s staffing resources for these activities. In addition to the contact named above, Geri Redican-Bigott, Assistant Director; Kye Briesath; Cathy Hamann; Rebecca Hendrickson; Richard Lipinski; Emily Loriso; Kevin Milne; Lisa Motley; and Patricia Roy made key contributions to this report. Information Technology: FDA Needs to Establish Key Plans and Processes for Guiding Systems Modernization Efforts. GAO-09-523. June 2, 2009. High-Risk Series: An Update. GAO-09-271. Washington, D.C.: January 2009. Food Safety: Improvements Needed in FDA Oversight of Fresh Produce. GAO-08-1047. Washington, D.C.: September 26, 2008. Drug Safety: Better Data Management and More Inspections Are Needed to Strengthen FDA’s Foreign Drug Inspection Program. GAO-08-970. Washington, D.C.: September 22, 2008. Food Labeling: FDA Needs to Better Leverage Resources, Improve Oversight, and Effectively Use Available Data to Help Consumers Select Healthy Foods. GAO-08-597. Washington, D.C.: September 9, 2008. Prescription Drugs: FDA’s Oversight of the Promotion of Drugs for Off- Label Uses. GAO-08-835. Washington, D.C.: July 28, 2008. Medical Devices: FDA Faces Challenges in Conducting Inspections of Foreign Manufacturing Establishments. GAO-08-780T. Washington, D.C.: May 14, 2008. New Drug Development: Science, Business, Regulatory, and Intellectual Property Issues Cited as Hampering Drug Development Efforts. GAO-07-49. Washington, D.C.: November 17, 2006. Food and Drug Administration: Effect of User Fees on Drug Approval Times, Withdrawals, and Other Agency Activities. GAO-02-958. Washington, D.C.: September 17, 2002. FDA Resources: Comprehensive Assessment of Staffing, Facilities, and Equipment Needed. GAO/HRD-89-142. Washington, D.C.: September 15, 1989.

Summary: Twenty years ago, GAO reported that the Food and Drug Administration (FDA) was concerned that it lacked resources to fulfill its mission, which includes oversight of the safety and effectiveness of medical products--human drugs, biologics, and medical devices--marketed for sale in the United States. Since then, FDA, GAO, and others have raised concerns regarding FDA's ability to meet its oversight responsibilities. GAO was asked to review the resources supporting FDA's medical product oversight responsibilities. GAO examined trends in (1) FDA's funding and staffing resources for its medical product oversight responsibilities from fiscal years 1999 through 2008, and (2) FDA's medical product oversight responsibilities during this same period. GAO analyzed FDA data on the agency's resources and workload, reviewed relevant federal laws, and interviewed FDA officials. GAO also examined more-detailed data on FDA's fiscal year 2004 through 2008 resources and workload in four key areas, representing a range of FDA's oversight responsibilities, both before and after a medical product is marketed in the United States. Funding and staffing resources for FDA's medical product programs increased between fiscal years 1999 and 2008, primarily as a result of increased user fees paid by industry, which are made available through appropriations acts to support the agency's processes for reviewing new medical products. Total funding increased from about $562 million in fiscal year 1999 to about $1.2 billion in fiscal year 2008, with user fee funding accounting for more than half of this increase. A large and growing portion of funding supported activities for which user fees are collected, resulting in a declining share of funding available for other activities. FDA officials said that this has seriously limited the agency's ability to fulfill its oversight responsibilities in some areas, particularly those not funded with user fees. FDA faced challenges fulfilling and managing its growing medical product oversight responsibilities, which agency officials attributed to resource constraints. FDA's statutory responsibilities grew during this period and a growing number of medical products subject to FDA oversight and establishments manufacturing these products for the U.S. market also added to the agency's workload. However, FDA could not provide data showing its workload and accomplishments in some areas, such as its review of reports identifying potential safety issues with specific medical products. Without such information, FDA cannot develop complete and reliable estimates of its resource needs. While FDA officials said that the funding amounts requested for and provided to FDA during the past 2 years will permit the agency to respond to its most urgent needs and priorities, officials also noted that they did not receive enough resources to meet some statutory requirements, such as biennially inspecting certain manufacturing establishments. Furthermore, officials said that the agency faces significant challenges fulfilling its mission to oversee the safety and effectiveness of medical products.