PT - JOURNAL ARTICLE AU - James F. Phillips AU - Bruce B. MacLeod AU - S. Patrick Kachur TI - Bugs in the Bed: Addressing the Contradictions of Embedded Science with Agile Implementation Research AID - 10.9745/GHSP-D-20-00169 DP - 2021 Feb 09 TA - Global Health: Science and Practice 4099 - http://www.ghspjournal.org/content/early/2021/02/04/GHSP-D-20-00169.short 4100 - http://www.ghspjournal.org/content/early/2021/02/04/GHSP-D-20-00169.full AB - Key FindingsEmbedding research into host program management and policy processes fostered the utilization of evidence for community-based health service development in Bangladesh, Ghana, and Tanzania. However, in each of these cases, strategies were required to offset challenges to the application of the embedded science approach.Research designs that maximize statistical rigor can be inconsistent with optimizing utilization. Achieving evidence-driven organizational change required phases for sequential learning to support systems development decision making.Key ImplicationsAgile science methods can address the inherent contradictions of embedded science health systems development in low- and middle-income country settings without compromising scientific rigor.Research aims should target the goal of achieving programmatic improvement as an endpoint that supplements demographic and health goals. To that end, phases of agile implementation research can overlap and curate knowledge, facilitating the institutionalization of evidence-based learning.The principles of agile development are potentially relevant to health systems strengthening in low- and middle-income country settings. Implementation research often fails to have its intended impact on what programs actually do. Embedding research within target organizational systems represents an effective response to this problem. However, contradictions associated with the approach often prevent its application. We present case studies of the application of embedded implementation research in Bangladesh, Ghana, and Tanzania where initiatives to strengthen community-based health systems were conducted using the embedded science model. In 2 of the cases, implementation research standards that are typically embraced without question were abandoned to ensure pursuit of embedded science. In the third example, statistical rigor was sustained, but this feature of the design was inconsistent with embedded science. In general, rigorous statistical designs employ units of observation that are inconsistent with organizational units that managers can control. Structural contradictions impede host institution ownership of research processes and utilization of results. Moreover, principles of scientific protocol leadership are inconsistent with managerial leadership. These and other embedded implementation science attributes are reviewed together with contradictions that challenged their pursuit in each case. Based on strategies that were effectively applied to offsetting challenges, a process of merging research with management is proposed that is derived from computer science. Known as “agile science,” this paradigm combines scientific rigor with management decision making. This agile embedded research approach is designed to sustain scientific rigor while optimizing the integration of learning into managerial decision making.